The risk for myocardial infarction (MI) in patients with spondyloarthritis (SpA) is increased in patients taking diclofenac, but not in patients taking naproxen, according to the results of nested case-control studies published in Annals of the Rheumatic Diseases. Results also show that MI risk with diclofenac in SpA differs from the risk in osteoarthritis (OA).

The investigators sought to characterize risk for MI in patients with SpA who were prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and to compare the pattern of risk observed in SpA with that in OA. Researchers performed nested case-control studies using The Health Improvement Network (THIN). Underlying cohorts included individuals with incident SpA or OA who had ≥1 NSAID prescription and no prior history of MI. In all cohorts, each MI case was matched with 4 controls without MI. Use of NSAIDs was categorized as follows: current (date of prescription 0 to 180 days prior to index date), recent (date of prescription 181 to 365 days prior to index date), and remote (date of prescription >365 days prior to index date).

There were a total of 8140 patients in the SpA cohort and 244,399 patients in the OA cohort. Overall, 115 and 6287 cases of MI were reported in patients with SpA and OA, respectively. After adjustment, current diclofenac use in SpA was associated with an odds ratio (OR) of 3.32 (95% CI, 1.57-7.03) for MI. In contrast, naproxen use was not associated with any increased risk for MI (adjusted OR, 1.19; 95% CI, 0.53-2.68). The ratio of ORs for patients with SpA taking diclofenac vs patients with OA taking diclofenac was 2.64 (95% CI, 1.24-5.58).

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The investigators concluded that the MI risk in diclofenac-treated patients with SpA differs from that in diclofenac-treated patients with OA. The current use of diclofenac in patients with SpA is associated with a 2- to 3-fold increased risk for MI relative to the remote use of any NSAID. If these findings are verified in other large SpA cohorts, this may influence a change in practice guidelines to recommend naproxen as the preferred first-line NSAID in patients with SpA.

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Dubreuil M, Louie-Gao Q, Peloquin CE, Choi HK, Zhang Y, Neogi T. Risk of myocardial infarction with use of selected non-steroidal anti-inflammatory drugs in patients with spondyloarthritis and osteoarthritis [published online April 19, 2018].  Ann Rheum Dis. doi:10.1136/annrheumdis-2018-213089