Gout afflicts about 2% of men over age 30 and women over age 50 and its prevalence appears to be increasing.1 In the United States in 2005, an estimated 3 million adults had suffered an episode of gout in the preceding year.2 Health care utilization costs associated with the disorder are substantial.3
Options for treating acute gout include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and intra-articular and systemic corticosteroids.4 Choosing among them can be challenging, however, because the evidence that one or another of these options yields real benefit is of varying strength. Using NSAIDs can be problematic with increasing age, as comorbidities like gastrointestinal (GI) bleeding, renal failure, heart failure, and cardiovascular risk increase and anticoagulant therapy is more likely to be in use.5 That’s where the kind of systematic reviews Cochrane Musculoskeletal Group (CMSG) performs can be of real help.
How this series can help you
This article is the first in a series intended to bring the findings of the Cochrane Musculoskeletal Group (CMSG) to the attention of family physicians. CMSG—one of the largest review groups that comprises the Cochrane Collaboration—includes more than 200 active researchers, health care professionals, and consumer representatives from 26 countries. The group synthesizes the results of high-quality clinical trials to determine whether interventions for the prevention, treatment, and rehabilitation of musculoskeletal disorders are safe and effective. Each article in this series will summarize a CMSG review on a single topic, using common clinical scenarios to demonstrate how the information the review supplies can be applied to clinical practice.
Colchicine and steroids: What the reviews tell us
The CMSG has done 2 systematic reviews of acute gout therapy. In 1, Schlesinger and colleagues went over all the available clinical trials to assess the efficacy and adverse effects of colchicine compared to placebo or to other acute gout treatments.6 In the other, Janssens and colleagues performed a similar review to assess the efficacy and safety of systemic corticosteroids in the treatment of acute gout in comparison with placebo, other acute gout treatments, or no therapy.7
Colchicine. Only 1 randomized controlled trial (RCT) of colchicine was identified.6 The trial included 43 participants (mostly men) who were treated with either colchicine or placebo, and the effects of treatment in both groups were compared. Colchicine was given as an initial dose of 1 mg orally followed by 0.5 mg every 2 hours until the acute episode subsided or toxic side effects occurred.
All 22 participants who took colchicine developed diarrhea or vomiting within 24 hours of initiating therapy, after taking a mean dose of 6.7 mg. In other words, the number needed to harm from colchicine therapy given in this way was 1. Three patients had to be treated in order to achieve at least a 50% decrease in pain.
No RCTs comparing colchicine with other treatments of acute gout were found. Case reports suggest that lower doses (0.5 mg, 3 times a day or less) of colchicine may be associated with fewer GI side effects, but there was no RCT evidence to support this approach.8
Systemic corticosteroids. No placebo-controlled trials of either intra-articular or systemic corticosteroids were found. Three trials involving 148 patients compared different systemic corticosteroids with different control drugs.7
Intramuscular (IM) triamcinolone acetonide 60 mg was compared with oral indomethacin 50 mg 3 times daily in 1 trial, and with IM adrenocorticotropic hormone (ACTH) 40 IU in a second trial. In a third trial, oral prednisolone (30 mg daily for 5 days) was compared with an initial single IM injection of 75 mg diclofenac followed by oral indomethacin 50 mg 3 times a day for 3 days, and then a reduced dose of 25 mg indomethacin 3 times a day for another 3 days.
No clinically relevant differences between the corticosteroids and the comparator drugs were found in any of the 3 trials. No important safety problems were attributed to the corticosteroid medications. Most adverse events were related to the comparator drugs—in particular to the NSAIDs. In view of the low quality and variability in the design of the trials, the review authors could not draw firm conclusions about the comparative effectiveness of systemic corticosteroids and the other drugs used.
Another study comes on heels of Cochrane review
A further RCT in progress at the time of the review compared oral prednisolone 35 mg daily with naproxen 500 mg twice daily for 5 days in 120 patients. This trial has since been published.9 It was a double-blind, double-dummy RCT with adequate allocation concealment, low loss to follow up, and thus low risk of bias.10 The results showed that the 2 interventions were clinically equivalent, with a 73% and 78% decrease in pain score over 90 hours in the prednisolone and naproxen groups, respectively. Most of the improvement occurred during the first 42 hours. Adverse events did not differ between groups.