Side Effects of Medication in Ankylosing Spondylitis Patients

Q: Side Effects of Medication in Ankylosing Spondylitis Patients

Hello, thank you for your questions. <br>Here are my responses：<br>1) Based on the described situation, is the likelihood of lower gastrointestinal bleeding high? --> I believe the probability of lower gastrointestinal bleeding is higher, especially due to hemorrhoids.<br>2) In t

Side effects of medication?

Hello Doctor: I am a patient with ankylosing spondylitis, currently 20 years old.
I started taking Celebrex a year ago.
Recently, four days ago, I began experiencing blood in my stool (bright red, present with every bowel movement), without any blood clots, and the toilet water has been stained red.
I noticed that there was no obvious blood on the surface of the stool (I am unsure if this is because it has dissolved in the water, making it hard to see any blood on the stool).
The shape of the stool is normal, and I can pass it easily (only a slight feeling of hardness, but it is minimal).
My bowel habits have not changed (about once every 1-2 days), and I have not experienced diarrhea, abdominal pain, or any other unusual symptoms.
The day before yesterday, I visited a colorectal surgeon, and I informed the doctor about my use of Celebrex.
The doctor performed a digital examination and mentioned feeling something related to internal hemorrhoids, so I was given suppositories for treatment.
However, since that doctor is not a rheumatologist and may not be familiar with Celebrex, I would like to confirm with you, Dr.
Gao.
The package insert for Celebrex mentions a very small risk of gastrointestinal bleeding and hemorrhoids as side effects.
I would like to ask you: 1) Based on the description above, is the likelihood of lower gastrointestinal bleeding high? 2) Is it true that the gastrointestinal bleeding side effects mentioned in the Celebrex package insert are mostly related to upper gastrointestinal bleeding, while lower gastrointestinal bleeding is relatively rare or even absent (assuming hemorrhoids do not count as lower gastrointestinal bleeding)? I think this because my rheumatologist has emphasized the importance of checking for black stools occasionally while on medication.
3) If it is hemorrhoids, how can I determine whether it was caused by taking Celebrex or if it is something that would occur in a normal person? 4) Recently, my school (sophomore year) conducted a health check, and my ALT was 34.
Over the past year while taking Celebrex, my ALT during follow-up blood tests has generally ranged between 21-12.
Earlier, during my first-year health check, my ALT was 25.
Should I be concerned that my liver may have issues due to the medication? 5) Additionally, could you please tell me what the normal values for CRP and hsCRP are for patients with ankylosing spondylitis? Is it better to test for CRP or hsCRP? (I ask this because I found online that the normal value for CRP is generally 0.5 mg/dL, but some hospitals report the normal value for hsCRP as 0.75 mg/dL, while other articles suggest it should be 0.3 mg/dL or even 0.1 mg/dL, which shows a significant discrepancy.) 6) If I strongly suspect that my ankylosing spondylitis symptoms have worsened due to receiving the first dose of the BNT vaccine, is there currently a medical method to prove this? Thank you, Doctor.

Zheng, 20~29 year old female. Ask Date: 2022/02/11

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your questions.
Here are my responses:
1) Based on the described situation, is the likelihood of lower gastrointestinal bleeding high? --> I believe the probability of lower gastrointestinal bleeding is higher, especially due to hemorrhoids.
2) In the package insert for Celecoxib, are most gastrointestinal bleeding side effects primarily upper gastrointestinal bleeding, while lower gastrointestinal bleeding is relatively rare or even nonexistent (assuming hemorrhoids are not classified as lower gastrointestinal bleeding)? I think this because my rheumatologist has emphasized checking for black stools occasionally while taking the medication.
--> Most cases are upper gastrointestinal bleeding.
Generally, Celecoxib is very safe, and bleeding side effects are rare.
3) If it is hemorrhoids, how can I determine whether it is caused by taking Celecoxib or if it is something that would occur in a normal person? --> Celecoxib is rarely the cause of hemorrhoids, so it is often due to lifestyle habits, which we both have the potential for, and it should not be related to Celecoxib.
4) Recently, my school (sophomore year) conducted a health check, and my ALT was 34.
Over the past year while taking Celecoxib, my ALT levels during follow-up blood tests have ranged from 21 to 12.
Earlier, during a health check in my first year of high school, my ALT was 25.
Doctor, should I be concerned that my liver may have issues due to the medication? --> Sometimes anti-inflammatory pain relievers can cause abnormal liver enzyme levels, including Celecoxib, but this is often temporary.
If liver enzyme levels remain abnormal during the next follow-up, we may consider a liver ultrasound.
If we suspect Celecoxib is the cause, we will also evaluate the severity of the liver enzyme abnormalities to decide whether to discontinue the medication.
5) Additionally, Doctor, what are the normal values for CRP and hsCRP in patients with ankylosing spondylitis? Is it better to test for CRP or hsCRP? (I ask this because I found online that the normal value for CRP is generally 0.5 mg/dL, but some hospitals report the normal value for hsCRP as 0.75 mg/dL, while other articles state it should be 0.3 mg/dL or even 0.1 mg/dL, which varies significantly.) --> Each hospital may have different testing methods, and reference normal values may vary slightly.
Generally, hsCRP is more accurate.
6) If I strongly suspect that the first dose of the BNT vaccine has worsened my ankylosing symptoms, is there currently a medical method to prove this? --> Currently, there is no method to confirm the correlation between the vaccine and the worsening of symptoms; we can only strongly suspect it.
Generally, side effects caused by vaccines are mostly temporary, so it is advised not to worry too much.
Changhua Hospital, Department of Allergy, Immunology, and Rheumatology, cares about you.

Reply Date: 2022/02/11

More Info

As a patient with ankylosing spondylitis (AS), it is essential to be vigilant about the medications you are taking and their potential side effects. You mentioned that you have been taking Secukinumab (brand name Cosentyx) for about a year and have recently experienced fresh blood in your stool. This situation raises several important questions regarding gastrointestinal (GI) side effects, particularly concerning the risk of lower GI bleeding, the relationship between your medication and any potential rectal issues, and the monitoring of liver function and inflammatory markers.

1. Risk of Lower Gastrointestinal Bleeding: The occurrence of fresh blood in your stool can be concerning. While Secukinumab has a low incidence of gastrointestinal bleeding, it is crucial to consider that any new GI symptoms should be evaluated thoroughly. The presence of blood, even if it is bright red, can indicate a lower GI issue, such as hemorrhoids or other conditions. Given that your doctor has noted the presence of internal hemorrhoids, this could be the source of the bleeding. However, it is essential to monitor this symptom closely and report any changes or worsening to your healthcare provider.

2. Upper vs. Lower GI Bleeding: The gastrointestinal bleeding associated with medications like Secukinumab is more commonly linked to upper GI bleeding (e.g., from the stomach or duodenum). Lower GI bleeding, while less common, can occur, especially in patients with pre-existing conditions. Your understanding that the majority of GI bleeding reported in medication side effects tends to be upper GI is correct. However, it is vital to consider all possibilities, including hemorrhoids, which can occur in the general population regardless of medication use.

3. Identifying Hemorrhoids: To determine whether your hemorrhoids are related to Secukinumab or are a common occurrence, consider the following: if you have a history of constipation or straining during bowel movements, this could contribute to the development of hemorrhoids. It is also worth noting that some medications can lead to constipation, which may exacerbate hemorrhoid symptoms. If your symptoms persist or worsen, further evaluation by a gastroenterologist may be warranted.

4. Liver Function Monitoring: Your ALT levels have shown some variability but remain within a generally acceptable range. While Secukinumab is not typically associated with significant liver toxicity, it is prudent to continue monitoring liver function tests regularly, especially if you have any concerns. If your ALT levels rise significantly or if you develop symptoms such as jaundice, abdominal pain, or unexplained fatigue, you should consult your healthcare provider promptly.

5. CRP and hsCRP Levels: For patients with ankylosing spondylitis, C-reactive protein (CRP) and high-sensitivity CRP (hsCRP) are important markers of inflammation. Normal values can vary between laboratories, but generally, a CRP level below 0.5 mg/dL is considered normal, while hsCRP may have a lower threshold, often cited around 0.3 mg/dL. It is advisable to discuss with your rheumatologist which test is more appropriate for your situation, as hsCRP can provide a more sensitive measure of inflammation.

6. Impact of Vaccination on Symptoms: Regarding your concerns about the BNT vaccine exacerbating your AS symptoms, while some patients report changes in their condition following vaccination, robust scientific evidence linking vaccination to worsening AS is limited. If you suspect a significant change in your symptoms post-vaccination, it is essential to discuss this with your rheumatologist, who can help assess your symptoms and determine the best course of action.

In summary, it is crucial to maintain open communication with your healthcare providers about any new symptoms or concerns. Regular monitoring of your condition, including liver function and inflammatory markers, along with appropriate management of any gastrointestinal symptoms, will help ensure your overall health and well-being while managing ankylosing spondylitis.

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