Corticosteroids may be viable first-line alternative to NSAIDs for acute gout

Oral corticosteroids showed similar effectiveness to nonsteroidal anti-inflammatory drugs (NSAIDs) for acute gout, a recent study found.

A double-blind equivalence trial randomized 416 adult patients with acute gout to oral prednisolone or oral indomethacin at 4 EDs in Hong Kong. Most patients were male, and the mean age was 65 years. The trial compared the efficacy and safety of the drugs. Results were published online on Feb. 23 by Annals of Internal Medicine.

Researchers measured the primary outcome, analgesic efficacy, by assessing pain in the worst affected joint with a visual analogue scale, which ranged from 0 mm (complete absence of pain) to 100 mm (the most severe pain). Analgesic efficacy was defined as changes in pain (at rest or with activity) greater than 13 mm. Researchers measured outcomes during the first 2 hours in the ED and from days 1 to 14. They also took note of the presence or absence of adverse events in each treatment group.

In the ED phase, researchers found no significant differences between groups in terms of pain score at rest (P=0.69). The mean decrease in pain score was 6.54 mm/h for indomethacin and 5.05 mm/h (95% CI, 3.56 to 6.55 mm/h) for prednisolone (mean difference, −1.49 mm/h). In terms of pain score with activity in the ED phase, researchers found no significant differences between groups (P=0.56). The mean decrease in pain score was 11.69 mm/h for indomethacin and 11.38 mm/h for prednisolone (mean difference, −0.31 mm/h).

Researchers also found no significant differences between groups (P=0.80) in pain score at rest from days 1 to 14. The mean decrease in pain score was 1.80 mm/d for indomethacin and 1.68 mm/d for prednisolone (mean difference, −0.12 mm/d). There were no significant differences between groups (P=0.20) in terms of pain score with activity from days 1 to 14. The mean decrease in pain score was 2.96 mm/d for indomethacin and 3.19 mm/d for prednisolone (mean difference, 0.22 mm/d).

No patient was found to have had a serious adverse event, although a greater proportion of indomethacin patients had minor adverse events in the ED phase (including dizziness, sleepiness, and nausea) and the post-ED phase (including nausea and vomiting).

The study provides “robust evidence that oral corticosteroids are as effective at treating pain and as acceptable to patients as NSAIDs and that they should be considered as a first-line alternative to NSAIDs in the treatment of patients with acute gout,” the authors concluded. They noted several potential limitations to the study, such as how the gout diagnoses were based on clinical criteria rather than joint aspiration, making it possible that some participants did not have gout. Additionally, they noted that their recruiting strategy may have missed 50% of eligible patients, including those with more severe symptoms, and that the findings pertaining to indomethacin may not be applicable to other NSAIDs in terms of adverse events.