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Steroids or Non-steroidals in the Treatment of Gout-like Arthritis
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Synopsis: Comparison of the use of steroids and non-steroidal medication plus Paracetamol in the treatment of gout-like arthritis.
Source: Man, CY, et al. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: A double-blind, randomized, controlled trial. Ann Emerg Med. 2007;49:670-677.
Acute gouty arthritis is the most common cause of joint inflammation in men over 40 years old. The disease is characterized by a crystal-induced inflammatory response in joints of middle age and elderly populations. The diagnosis of gouty arthritis is typically made clinically by the acute onset of a red, swollen, painful joint and by the presence of negatively birefringent uric acid crystals in joint aspirate. The diagnosis is often made without joint aspiration secondary to the difficulty of the procedure and lack of patient tolerance. The treatment of gouty arthritis is inconsistent, and evidence-based practice, according to Man and colleagues, is lacking. To that end, Man et al evaluated the use of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of gout-like arthritis.
Ninety patients, age 17 and older, who presented with acute arthritis suggestive of gout were enrolled in the study. Patients were included if they had a clinical diagnosis of gout defined as presence of pain and joint warmth. Also, the patient had to present within 3 days of onset, or had ankle or knee involvement and aspirate-containing crystals. Patients were excluded if they had a bleeding disorder, had suspicion of septic arthritis, a significant co-morbidity, or if they were lost to follow-up. Patients were randomized into the prednisolone group or into the indomethacin group.
Baseline characteristics, including pain scores, were similar in the 2 groups. Both treatments had a similar decrease in pain in the ED, and both treatment groups showed clinical improvement in joint swelling and stiffness; there was no significant statistical significance in improvement between the 2 groups. Both groups also took acetaminophen during the trial; on average the prednisolone groups took almost twice as much acetaminophen as the indomethacin group. Fifteen patients in the prednisolone group and 17 patients in the indomethacin group required additional treatment during the study.
However, 63% of the patients in the indomethacin group experienced side effects, compared to only 27% of patients in the prednisolone group. Indigestion, nausea, vomiting, epigastric pain, and dizziness were much more common in the indomethacin group. The most significant common adverse effects in the prednisolone group were dry mouth and dizziness. Seven patients, all from the indomethacin group, had serious side effects requiring hospitalization or out-patient treatment. Five of these patients developed GI bleeding. One of these patients was treated on an outpatient basis; the other 4 patients were admitted to the hospital.
This was the first study comparing 2 commonly available and inexpensive medications in the treatment of acute gout-like arthritis. The results showed that the treatment of acute gout-like arthritis with these 2 medications produced similar pain relief, although the patients in the prednisolone group took significantly more acetaminophen than the patients in the indomethacin group. Also, patients taking prednisolone had statistically significant fewer side effects than patients in the indomethacin group.
This study demonstrates that although NSAIDs are generally recommended as first line therapy in patients with acute gouty arthritis, a short course of corticosteroids could be used as an alternative for acute gout, particularly when NSAIDs are contraindicated, or as the first line treatment when combined with acetaminophen. In patients at risk for gastrointestinal bleeding, or where GI bleeding could have significant morbidity, such as the elderly, a short dose of corticosteroids combined with acetaminophen may be preferable to NSAIDs.
Many patients present to urgent care settings complaining of the rapid onset of pain, swelling, and inflammation of an affected joint. In patients who do not have an infectious etiology to their symptoms, this study demonstrates that we have alternatives to NSAIDs in the treatment of acute gouty arthritis.