Talk By Local Pharmacist to the Group - June 2002

At the regular meeting of the Taunton Branch of NASS held at the Musgrove Park Hospital,Taunton, local Pharmacist, Mervyn Clark, gave a talk on the drugs currently being used to treat the condition. He began by giving a general overview of the disease and its essential features.
As far as treatment is concerned he said that it fell into three; categories.viz.

1 Regular physiotherapy to maintain posture with exercise to stress back movements and a full range of spinal movements in all directions. Encourage straightening and deep forward bending movements to improve chest expansion. Hot baths or heat packs were useful before exercise.
2 Drug Treatment to cope with inflammation and associated pain.
He suggested that it was sensible to start with the simplest regime which provided adequate pain control. Paracetamol was the drug of choice, taken regularly at the correct dosage, but Co-Dydramol and Co-Proxamol were also used.
The next stage of drug treatment involved analgesics known as Non-Steroidal Anti-Inflammatory Drugs (NSAIDS). He explained that there were two groups of such drugs and explained their differing modes of action. He suggested that the first group be used in an ascending order depending on the balance between their anti-inflammatory activity and their side-effects.viz.,
Ibuprofen
Diclofenac / Naproxen
Piroxicam /Ketoprofen /Indomethacin.
Azopropazone.
He explained that the various side-effects varied from person to person dependent upon their own physiology but that the commonest problems were indigestion and gastric reflux and the most serious being Gastro-intestinal bleeding and perforation. These side-effects accounted for nearly half of all problems reported.
The second group of NSAIDS were known as COX-2 inhibitors which worked, as he explained, in a different manner. The COX-2 NSAIDS currently being used were,
Celecoxib
Etodalac
Meloxicam
Rofecoxib
He explained the side-effects of these drugs and indicated that they were recommended for patients at greater risk of GI problems such as the elderly (over 65), those with a history of peptic ulcer disease and GI bleeding, smokers, diabetics, people on oral corticosteroids, and with coronary heart disease.
He went on to say that research has yet to prove that COX-2 inhibitors offered greater protection than standard NSAIDS.
3. The third group of drugs are known as Disease Modifying AntiRheumatic Drugs (DMARDS).

He explained that these drugs were not anti-inflammatory or exhibited analgesic properties but that they influence the disease process itself. i.e they slow the erosion associated with AS. They are slow acting drugs and can take up to 16 weeks to exert their full effect. Examples of DMARDS are
Sulfasalazine
Methotrexate
Penicillamine
Injectable gold
Hydroxychloroquine.
Some current thinking, he reported, was that patients newly diagnosed with AS should commence treatment with a DMARD as soon as possible so as to slow progression of the disease.

Mervyn Clark concluded his talk by summarising a few points:

1 NSAIDS should be taken regularly with milk or food and not on an ‘as required’ basis. This is because they need one to three weeks to achieve their full anti-inflammatory effect.
2 Patients on both standard NSAIDS and COX-2 inhibitors should report any discomfort to their GP without delay. A switch to another NSAID may avoid further problems.
3 Patients taking DMARDS should receive close monitoring by their GP. eg blood counts, Liver and Renal Function tests. Any minor illness should be reported to their GP because of the suppression of their immune systems by the DMARDS.
A review of the current medication of those attending was held which resulted in a lively question and answer session. There was some discussion of the current trial of the drug Etanercept (Enbrel) in the USA which was resulting in sustained improvements for AS sufferers. Further news of the result of this trial for British patients was eagerly awaited.