Publication highlighting the differential MI risk of various NSAIDs in spondyloarthritis and osteoarthritis

NSAIDs and risk of myocardial infarction in patients with #spondyloarthritis #osteoarthritis: highest risk with current diclofenac use, with risk of event highest in SpA patients









the rheumatologist
Diclofenac May Boost MI Risk in Patients with Spondyloarthritis

May 7, 2018 • By Marilynn Larkin

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NEW YORK (Reuters Health)—Risk of myocardial infarction (MI) is increased in patients with spondyloarthritis (SpA) who use the nonsteroidal anti-inflammatory drug (NSAID) diclofenac, but not in those who take naproxen, researchers say.

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Maureen Dubreuil, MD, MSc, of Boston University School of Medicine, and colleagues analyzed 20 years of medical records from the U.K.’s Health Improvement Network for adults ages 18–89 with incident ankylosing spondylitis (AS) or psoriatic arthritis (PsA), two forms of SpA. Controls had incident osteoarthritis (OA).

Within each cohort, the team then matched each MI case to four controls without MI.

NSAID use was categorized as a) current (prescription within 180 days prior to index date); b) recent (181-365 days); or c) remote (>365 days).

The daily dosage of diclofenac was 100 mg or more in 92% of individuals with OA, 95% of those with AS and 92% of those with PsA. The most common daily dosage of naproxen was 1,000 mg (55%); the dose was 1,000 mg or more in 56% of patients with OA, 63% of those with AS and 72% of those with PsA.

Among those whose most recent prescription was an NSAID other than diclofenac or naproxen, the most common drugs were ibuprofen (55%), celecoxib (11%), meloxicam (10%), rofecoxib (7%), etoricoxib (5%), indomethacin (3%) and etodolac (3%). All other NSAIDs accounted for 2% or less of prescriptions.

Within the SpA cohort of 8,140 and the OA cohort of 244,339, there were 115 and 6,287 cases of MI, respectively.

As reported online April 19 in Annals of Rheumatic Diseases, current diclofenac use was associated with an adjusted OR of 3.32 for MI in SpA patients. The risk was also increased in those with OA (aOR, 1.26).1

A similar pattern was seen with current use of other NSAIDs (aOR, 1.17), but not with current naproxen use (aOR 0.98).

Because current diclofenac was associated with increased MI risk, the authors also assessed whether recent use (18–365 days from prescription date) conferred risk. The unadjusted OR for recent use in SpA was 1.45, and in OA, 0.94. By contrast, recent naproxen was not associated with an increased or decreased risk in either SpA or OA.

Overall, the authors state, “Current use of diclofenac in SpA was associated with a twofold to threefold risk of MI relative to remote use of any NSAID.”

“[Although] this finding warrants some concern,” Dr. Dubreuil tells Reuters Health, “similar studies should be conducted in other data sets and other populations to help determine if a change in clinical practice is warranted.”

“If confirmed,” she says by email, “it is possible that subsequent treatment guidelines would recommend for or against a specific NSAID as first-line treatment in spondyloarthritis.”

Daniel Solomon, MD, MPH, chief, Section of Clinical Sciences, Divisions of Rheumatology and Pharmacoepidemiology at Brigham and Women’s Hospital in Boston comments to Reuters Health by email, “We know that all NSAIDs confer cardiovascular [CV] risk. However, most patients with normal CV risk who use these agents intermittently will not experience harm. Chronic use of NSAIDs in patients with certain risk factors is associated with substantial potential for CV and other adverse events.”

“The best data we have on these issues comes from large randomized controlled trials, such as PRECISION which tested different NSAIDs across patients with osteoarthritis (OA) or rheumatoid arthritis (RA),” says Dr. Solomon, who was a coauthor on PRECISION.2

“No important differences were found in relative risks across different NSAIDs by disease,” he notes. “In other words, patients with OA and RA experienced the same relative risks by NSAID. However, the CV risk was higher in RA so absolute risks were higher for the RA patients.”

The authors of the current study “specifically examined patients with spondyloarthritis and with OA and found that use of current diclofenac conferred an increased relative risk for CV events compared to past use among both patient groups, but the relative risk was increased for SpA compared with OA,” he says.

“This is interesting and there are biologic reasons why this is plausible,” he says, “but by no means are these results practice-changing. NSAID observational studies are very tricky because of confounding by indication as well as over the counter NSAID use. These results should generate new hypotheses that might be tested in prospective cohorts.”

Patients should not be told to steer clear of diclofenac, he adds. “All NSAIDs, including celecoxib, confer CV, gastrointestinal and renal risk. Patients should not use these agents chronically if they have known CV or renal disease.”


  1. Dubreuil M, Louie-Gao Q, Peloquin CE, et al. Risk of myocardial infarction with use of selected non-steroidal anti-inflammatory drugs in patients with spondyloarthritis and osteoarthritis. Ann Rheum Dis. 2018 Apr 19. pii: annrheumdis-2018-213089. [Epub ahead of print]
  2. Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.


Tuhina Neogi named Chair for 2019 OARSI Meeting




Tuhina Neogi has been appointed as Program Chair for the 2019 Osteoarthritis Research Society International (OARSI) Congress, to take place in Toronto, Ontario, Canada May 2 – 5, 2019

Tuhina Neogi — ACR Gout Treatment Guidelines

Tuhina Neogi has been named as a co-PI for the American College of Rheumatology (ACR) Gout Treatment Guidelines Update.

Please join us in congratulating Tuhina on her participation in this important contribution to the treatment of gout!

Congratulations to Dr. Maureen Dubreuil, MD, MSc

for being selected as a recipient of the 2018 SAA/Bruckel Early Career Investigator in #AxSpA Award #spotspondy

June 18, 2018

MD award 2018BU researcher recognized for outstanding contributions in the field of spondyloarthritis

Boston University School of Medicine

(Boston)–Maureen Dubreuil, MD, MSc, assistant professor of Clinical Epidemiology Research & Training at Boston University School of Medicine (BUSM), is one of two recipients of the 2018 Spondylitis Association of America (SAA) Bruckel Early Career Investigator in Axial Spondyloarthritis Award.

Spondyloarthritis is a type of arthritis that attacks the spine and, in some people, the joints of the arms and legs. Dubreuil’s research focuses on comorbidities and pharmacoepidemiology of spondyloarthritis. She is currently studying patient preferences and the cost-effectiveness of treatment modalities for this disease. The $20,000 award will help this ongoing research.

The award was created to recognize outstanding “contributions to the care and understanding of patients with spondyloarthritis.” It was named in honor of the SAA’s co-founder Jane Bruckel and is given annually to the early career investigator who shows the most promise to contribute to the understanding or therapy of axial spondyloarthritis.

One theme of Dubreuil’s work is heart disease in spondyloarthritis. She led a study that examined the risk of heart attacks with non-steroidal anti-inflammatory drugs (NSAIDs) in spondyloarthritis patients, using a large database from the United Kingdom. The study found that specific NSAIDs may increase risk of heart attacks to a greater degree in people with spondyloarthritis than those with osteoarthritis. She is studying this same topic in other populations, including a large database in the United States. Dubreuil also collaborated on a study of the effects of statin (cholesterol medication) use in ankylosing spondylitis, finding that statins appear to have a more protective effect in people with ankylosing spondylitis than in the general population.

“A second theme of my work is understanding patients’ preferences for treatments in spondyloarthritis,” she explained. In 2016 she began work on a National Institutes of Health-funded project to assess factors that influence spondyloarthritis patients’ preferences for medications. “In the coming year, I will begin work on a cost-effectiveness study, comparing different approaches to spondyloarthritis treatment, such as starting with an NSAID versus starting with a biologic medication.”


Dubreuil is a member of the Spondyloarthritis Research and Treatment Network (SPARTAN), and of the Assessment of Spondyloarthritis International Society (ASAS), and serves on the Early Career Investigator Subcommittee of the American College of Rheumatology. In 2013, she was awarded the Arthritis Foundation Clinical to Research Transition Award and 2016, she began work on a K23-funded project to study patient preferences, and the cost-effectiveness of treatment modalities for spondyloarthritis, to inform both clinical care and policy decisions.

BU CTSI Natural Language Processing Symposium

Wednesday, December 13, 2017

The CTSI was delighted to host the Natural Language Processing Symposium. A distinguished panel of speakers gathered for a symposium on Natural Language Processing and Machine Learning at BU to learn how we may incorporate these methods into future studies in EMR database.

This symposium was sponsored by:
Wing Tat Lee Endowment- Supports collaborations between BUSM faculty and faculty at a mainland Chinese university (with preference for Hong Kong). The cooperative programs may include training faculty from either institution; holding seminars, workshops and symposia; and carrying out research projects of common interest.

FINAL Program

David Felson honored as Master of the ACR at 2017 Annual Meeting in San Diego

ACR Public Release: 3-Nov-2017

American College of Rheumatology announces 2017 award recipients

Leading rheumatology researchers and thought leaders honored for accomplishments and service

American College of Rheumatology

ATLANTA – The American College of Rheumatology (ACR) announced the 2017 recipients of its Master of the ACR designation, Awards of Distinction, and Distinguished Fellow Award honors during the opening lecture of the 2017 ACR/ARHP Annual Meeting in San Diego. These recognitions are given annually to members who exhibit outstanding contributions to the field of rheumatology.

Master of the ACR Designation

Recognition as a Master is one of the highest honors that the College bestows on its distinguished members. The designation of Master is conferred on ACR members, age 65 or older, who have made outstanding contributions to the field of rheumatology through scholarly achievement and/or service to their patients, students, and the rheumatology profession. These honorees have devoted their long careers to furthering rheumatology research and improving clinical standards in the treatment of rheumatic diseases.

Among the 2017 recipients of the Masters of the ACR designation is:

  • David Felson, MD, MPH, Boston University School of Medicine, Clinical Research Training Unit, Boston, MA


About the ACR/ARHP Annual Meeting

The ACR/ARHP Annual Meeting is the premier meeting in rheumatology. With more than 450 sessions and thousands of abstracts, if offers a superior combination of basic science, clinical science, tech-med courses, career enhancement education and interactive discussions on improving patient care. For more information about the meeting, visit, or join the conversation on Twitter by following the official #ACR17 hashtag.

About the American College of Rheumatology

The American College of Rheumatology is an international medical society representing over 9,400 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit

What Causes the Lasting Insult in Knee OA?

Dec 6, 2014

Interview originally appeared on December 5, 2014 | ACR 2014, Arthritis, Osteoarthritis, Rheumatologic Pain

Watch the video here


By Tuhina Neogi MD

Rheumatology Network

For some patients with knee osteoarthritis, pain signals are centralized and become more intense, rather than waning with time. Is this caused by continuing injury to the damaged knee, or is inflammation more prominent?

In this video, researcher Tuhina Neogi of Boston University School of Medicine describes research presented at the 2014 annual meeting of the American College of Rheumatology that addressed this question by assessing specific signs of inflammation (synovitis and effusion on MRI) and noninflammatory tissue injury (bone marrow lesions) with relation to the development of central sensitization of pain.

An Associate Professor at Boston University School of Medicine, Dr. Neogi studies the epidemiology of rheumatic disease.

The questions:

You’ve been looking at the causes of sensitization of knee osteoarthritis pain. How do you define sensitization?

Can you tell us about the study that you presented at the ACR?

We’ve heard a lot lately about the fact that rheumatologists are able to address inflammation but they’re not so able to address pain. Do you think your findings have any practical implications with regard to what rheumatologists are or are not able to do?

If your listeners want to look for the next paper that carries this research forward, what might its title be? What should they be looking for?

Key quotes:

We and others have demonstrated that sensitization is associated with increased pain severity … and change in pain over time. But what we didn’t know is what causes sensitization in knee OA.

Inflammation likely contributes to sensitization in knee osteoarthritis, whereas bone marrow lesions do not appear to do so. Therefore, bone marrow lesions likely contribute to pain through other mechanisms.

We need to do some more studies to see if intervening early on these parameters of inflammation has an effect.

I think overall the take-home message for clinicians is that pain is a multifactorial symptom and we need to move more towards mechanism-based pain management that’s not a one-size-fits-all for everyone. … We cannot just say “This is the first step. This is the second step.” It has to become more personalized.


Neogi T, Nevitt MC, Scholz J, et al. Effect of Synovitis, Effusion and Bone Marrow Lesions on Development of Sensitization in Knee OA: The Multicenter Osteoarthritis Study ACR Abstract #2783, 2014 66:S1306. Abstract Supplement, 2014 ACR/ARHP Annual Meeting