What to Use for Acute Gout NSAIDs or Steroids?
Abstract & Commentary
By Joseph E. Scherger, MD, MPH. Dr. Scherger is Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study. This article originally appeared in the September 29, 2008 issue of Internal Medicine Alert. It was edited by Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD. Dr. Brunton is Clinical Professor, University of California, Irvine, and Dr. Roberts is Clinical Professor of Medicine, Albert Einstein College of Medicine. Dr. Brunton is a consultant for Sanofi-Aventis, Ortho-McNeil, McNeil, Abbott, Novo Nordisk, Eli Lilly, Endo, EXACT Sciences, and AstraZeneca, and serves on the speaker's bureau for McNeil, Sanofi-Aventis, and Ortho McNeil, and Dr. Roberts reports no financial relationships relevant to this field of study.
Synopsis: A randomized, controlled trial in the Netherlands showed that oral prednisolone and naproxen were equivalent in the treatment of acute gout with no difference in side effects.
Source: Janssens HJ, et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet 2008;371:1854-1860.
Primary care physicians in the Netherlands were encouraged to refer patients with acute monoarticular gout to a university-based general practice department for this study. After immediate diagnosis with crystal identification of joint fluid, 120 patients were randomized to receive either 35 mg of prednisolone once daily or 500 mg of naproxen twice daily for five days. The treatment was blinded with identical appearing pills, twice daily for both groups.
The pain resolution scores were nearly identical for both treatment options. Only one patient from each group had incomplete data and was excluded. Approximately two-thirds of patients in each group reported no treatment side effects. The rate of side effects was the same in each group for: gastric or abdominal pain (15%); itching or dizziness (7%); and dyspnea or palpitations (5%). Approximately 20% in each group experienced other unspecified side effects. By three weeks, all patients reported complete relief from the initial attack and no patients had a recurrence.
The treatment of acute gout has evolved gradually over the past 30 years. Colchicine is the historical standard and is so specific for acute gout that it has been used both diagnostically and therapeutically. But colchicine has a narrow therapeutic range and cannot be used in patients with renal insufficiency. Often the gastrointestinal (GI) side effects are harsh for the patient. The availability of NSAIDs over the past 30 years has led to their widespread use. However, NSAIDs have GI risks of their own and are problematic in patients with hypertension and heart failure, common comorbidities in patients with gout.
The option of using corticosteroids has been considered but not systematically studied. This randomized clinical trial is highly welcome since it uses the best evidence to show that the use of a moderate dose of prednisolone (35 mg, roughly equivalent to 40 mg of prednisone) is as effective as 1000 mg of naproxen. The bottom line for us now is to take our choice, or "pick our poison." Both are safe for most people. Naproxen may have more adverse effects, but a case of avascular necrosis from prednisone is horrendous. Neither drug is completely innocuous.
I have used naproxen 500 mg every six hours for 24-48 hours until the acute pain has subsided. In this study, prednisone worked as quickly as naproxen, but I wonder if it would work more quickly at a higher dose. The initial dosage of prednisone could be higher, and could be given in divided doses.
This was a simple and inexpensive study. Both medications are generic. I hope that other busy clinical centers will repeat this study with varying dosage schedules of the two drugs to provide further evidence of treatment preference.