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Evidence summaries

Systemic Corticosteroids for Acute Gout

Peroral corticosteroids may be as effective as naproxen in the initial treatment of acute gout. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 3 head to head studies with a total of 148 subjects. Placebo-controlled trials were not found. In the studies, different kinds of systemic corticosteroids and different kinds of control drugs were used, both administered in different routes. Intramuscular triamcinolone acetonide was compared respectively to oral indomethacine, and intramuscular adrenocorticotropic hormone (ACTH); oral prednisolone (together with a single intramuscular diclophenac injection) was compared to oral indomethacine (together with a single placebo injection). Outcome measurements varied: average number of days until total relief of signs, mean decrease of pain per unit of time in mm on a visual analogue scale (VAS) - during rest and activity. In the triamcinolone-indomethacine trial the clinical joint status was used as an additional outcome. Statistical pooling of results was not possible.

Clinically relevant differences between the studied systemic corticosteroids and the comparator drugs were not found; important safety problems attributable to the used corticosteroids were not reported.

In an RCT 2 120 primary care patients with monoarticular gout arthritis confirmed by identification of monosodium urate crystals in the synovial fluid of the affected joint were randomly assigned to receive either prednisolone (35 mg once a day; n=60) or naproxen (500 mg twice a day; n=60), for 5 days. Data were incomplete for one patient in each treatment group, so per-protocol analyses included 59 patients in each group. After 90 h the reduction in the pain score was 44·7 mm and 46·0 mm for prednisolone and naproxen, respectively (difference 1·3 mm; 95% CI 9·8 to 7·1), suggesting equivalence. The difference in the size of change in pain was 1·57 mm (95% CI 8·65 to 11·78). Adverse effects were similar between groups, minor, and resolved by 3 week follow-up.

Comment: The quality of evidence is downgraded by imprecise results (few patients studied).

    References

    • Janssens HJ, Lucassen PL, Van de Laar FA, Janssen M, Van de Lisdonk EH. Systemic corticosteroids for acute gout. Cochrane Database Syst Rev 2008 Apr 16;(2):CD005521. [PubMed]
    • Janssens HJEM 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/Secondary Keywords