NSAIDS on the patient with RA.

Daily I hear about patient’s very long lists of medications.  I recently was balancing an individual’s exercise progression in the face of changing medications.  So I quickly took to Pubmed to dig a little further into specific effects of certain medications on inflammation in a chronic inflammatory environment of Rheumatoid Arthritis (RA).

For this discussion, NSAIDS will consist of the nonselective (i.e. Naproxen and Ibuprofen) vs. COX-2 inhibitors (i.e.Celecoxib – only one on the US Market in 2012).  Nonselective NSAIDS have the adverse effects of peptic/GI ulcers.  But the COX-2 inhibitors risk significant cardiovascular events.

Using a C-reactive protein (CRP) as a biomarker for inflammation, it has been found that Naproxen does reduce inflammation in RA consistently.  But COX-2 inhibitors are inconsistent among research and actually appear to increase CRP and therefore increase cardiovascular risks in RA.

Further research has been unraveling CRP is an independent indicator for Cardiovascular health in RA patients.  This is troubling for heart attacks and strokes.  It has been stated by Goodson et al that CRP is a predictor of death by cardiovascular event but the reverse is not true.  Decreasing CRP does not reduce the number of cardiovascular events.

Although increasing inflammation is always a concern within the RA population, I was less concerned for this patient’s minor adjustments in her medications.  Between continued monitoring of symptoms and modifying the program the patient had no adverse reactions.

Of interest, polymyositis and SLE do not increase CRP inherently unless something like a synovitis is present.

Resources:

Tarp S, Bartels EM, Bliddal H, Furst DE, Boers M, Danneskoild-Samsoe B, Rasmussen M, Christensen R.  Effect of nonsteroidal antiinflammatory drugs on the C-reactive protein level in rheumatoid arthritis: A meta-analysis of randomized controlled trials.  Arthritis Rheum 2012; 64 (11): 3511-21.

Goodson NJ, Symmons DP, Scott DG, Bunn D, Lunt M, Silman AJ. Baseline Levels of C-reactive protein and prediction of death from cardiovascular disease in patients with inflammatory polyarthrits: a ten-year follow up study of a primary care-based inception cohort.  Arthritis Rheum 2005; 52: 2293-9.

 

 

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