Optimizing adherence to therapy in patients with non-specific back pain

Background:NSAIDs remain the first-line drugs in treatment of AS. During pregnancy, COX-2 non-selective NSAIDs are allowed for intake up to 32 weeks, but the question of the dose-dependent effect of NSAIDs on fetal organogenesis in the 1st trimester and on fetal kidney function and the increased risk of bleeding in childbirth when taken in the second half of pregnancy continues to be discussed. At the same time, data on the effectiveness of NSAIDs, including their low and medium doses, during pregnancy are extremely small.Objectives:to describe the frequency of using NSAIDs during pregnancy, to determine relationship between the dose of NSAIDs, adherence to therapy with the activity of AS.Methods:50 pregnancies were followed in 49 pregnant women with confirmed AS (modified New York criteria, 1984). The average age of the pts was 31.6 ± 4.9 years, the duration of the disease was 134.4 ± 85.8 months. The visits were conducted at 10-11, 20-21, and 31-32 weeks of pregnancy. The BASDAI in the month of conception and in the trimesters (trim.) of pregnancy was: 1,4[0,6; 3,3]; 2,3[1,2; 4,4]; 2,8[1,4; 4,2] and 2,2[1,6; 4,0], respectively. The level of nocturnal back pain according to the NRS in the first, second and third trim. was: 3.2±2.0; 5.4±2.5 and 5.2±2.6, respectively. The drug of choice was ibuprofen at a maximum daily dose of 1200 mg, its withdrawal - no later than 32 weeks of pregnancy.Adherence to NSAID therapy was defined as the ratio of the actual dose taken to the prescribed dose; an indicator of less than 80% was regarded as non-adherence to therapy. The total dose of NSAIDs was determined by the NSAID intake index (M. Dougados, 2001). The” actual daily dose” of ibuprofen was the sum of the doses of ibuprofen taken, divided by the number of actual days of taking the drug. The “average daily dose” was defined as the sum of the ibuprofen doses taken, divided by the number of days in the trimester.Results:At the time of conception and in the first, second and third trim. of pregnancy, NSAIDs were taken 23 (46%), 20 (40%), 30 (60%) and 21 (43.8%) women, respectively. The NSAID intake index, the actual and average daily dose of ibuprofen are shown in the Table 1.month of conceptiontrim. 1trim. 2trim. 3the actual daily dose, mg-700[425; 800]800[400; 1000]750[400; 1200]the average daily dose, mg-158[87,9; 307,7]355,1[138,5; 685,7]580[320; 1200]NSAIDs intake index28,6 [16,7; 50]5,8 [2,9; 11,8]15,5 [4,7; 30,9]24,4 [9,5; 50]The index of NSAID intake in the first trim. was lower than before pregnancy and in the second half of gestation (p<0.05 compared to the month of conception, II and III trim.). The average daily dose of ibuprofen was also lower in the first trim. than in the second and third trim. (p<0.05), while the actual daily dose in the second trim. was higher than in the first and third trim. (p<0.05 in all cases).There was no correlation between BASDAI AS activity, the level of nocturnal pain and the ibuprofen intake index, likewise the fact of NSAID withdrawal throughout pregnancy. In addition, there were no differences in BASDAI levels and back pain in women with a subjective need for NSAIDs, who did and did’t take ibuprofen.50% of women were committed to NSAID therapy in the first trim., 43.5% in the second trim., and 67.4% in the third trim. In pts with non-adherence to NSAID therapy, the BASDAI level was higher than in those who followed the recommendations of the rheumatologist throughout pregnancy: in the first trim. – 3.8[3.4; 4.7] and 1.7[0.8; 2.2]; in the second trim. - 3[2.3; 4.6] and 1.4[0.8; 2.7]; in the third trim. - 3.1[2.1; 4.0] and 1.7[1.1; 4.0], p<0.05 in all cases. However, women with adherence > 80% were initially less active and NSAIDs were prescribed “on demand”, which increased their compliance.Conclusion:intake of ibuprofen in low doses does not affect the activity of AS. Due to the ongoing discussion about the effect of NSAIDs on neonatal outcomes, further international studies are required for development an optimal treatment regimen during pregnancy with a possible extension of the indications for the appointment of TNF inhibitors (BASDAI<4).Disclosure of Interests:None declared.

Download Full-text

Nonspecific Chronic Back Pain: Sixth Edition Approaches

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2019.sepoct03 ◽

2019 ◽

Vol 24 (5) ◽

pp. 14-15

Author(s):

Jay Blaisdell ◽

James B. Talmage

Keyword(s):

Back Pain ◽

Chronic Back Pain ◽

Intervertebral Disk ◽

Key Factors ◽

Sixth Edition ◽

Whole Person ◽

Class 1 ◽

A Cell ◽

Intervertebral Disk Herniation ◽

The Individual

Abstract Ratings for “non-specific chronic, or chronic reoccurring, back pain” are based on the diagnosis-based impairment method whereby an impairment class, usually representing a range of impairment values within a cell of a grid, is selected by diagnosis and “specific criteria” (key factors). Within the impairment class, the default impairment value then can be modified using non-key factors or “grade modifiers” such as functional history, physical examination, and clinical studies using the net adjustment formula. The diagnosis of “nonspecific chronic, or chronic reoccurring, back pain” can be rated in class 0 and 1; the former has a default value of 0%, and the latter has a default value of 2% before any modifications. The key concept here is that the physician believes that the patient is experiencing pain, yet there are no related objective findings, most notably radiculopathy as distinguished from “nonverifiable radicular complaints.” If the individual is found not to have radiculopathy and the medical record shows that the patient has never had clinically verifiable radiculopathy, then the diagnosis of “intervertebral disk herniation and/or AOMSI [alteration of motion segment integrity] cannot be used.” If the patient is asymptomatic at maximum medical improvement, then impairment Class 0 should be chosen, not Class 1; a final whole person impairment rating of 1% indicates incorrect use of the methodology.

Download Full-text