Corticosteroids May Be an Effective Alternative to NSAIDs in Acute Gout Pain

A review published in the Annals of Emergency Medicine concluded that, among patients with gout, there is no significant difference between corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term pain relief, long-term pain relief, time to resolution of pain, or the need for additional analgesics.

The meta-analysis identified 6 trials that met the inclusion criteria and included a total of 817 patients. Although there was no difference for the primary safety outcome, defined as the rate of gastrointestinal bleeding, between corticosteroids and NSAIDs, the incidence of gastrointestinal adverse effects was lower in the corticosteroid group. The relative risk for corticosteroids vs NSAIDs was 0.25 for nausea (95% CI, 0.11-0.54), 0.11 for vomiting (95% CI, 0.02-0.56), 0.50 for indigestion (95% CI, 0.27-0.92), and 5.00 for hyperglycemia (95% CI, 0.25-99.95).

Subgroup analyses did not show differences among dosages or routes of administration (oral prednisolone vs intramuscular betamethasone and triamcinolone) for corticosteroids. A similar analysis for various NSAIDs was not conducted.

Joseph W. Watkins, IV, MD, and Rawle A. Seupaul, MD, of the Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, noted that pain from acute gout accounted for 200,000 emergency department visits in 2012. Gout affects up to 7% of elderly men. They add that the evidence in this review was graded as low to moderate quality according to GRADE methodology and suggested a need for additional prospective studies.

The authors also suggested that corticosteroids are helpful for patients for whom NSAIDs are either contraindicated, such as those with renal or liver dysfunction or coagulopathy, or discouraged, such as elderly patients or individuals with a history of peptic ulcer disease. Oral prednisolone 30 mg daily for 4 to 5 days was the most common dosing regimen for corticosteroids in these studies of acute gout.

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Reference

Watkins JW 4th, Seupaul RA. Are corticosteroids superior to nonsteroidal anti-inflammatory drugs in the treatment of acute gout? [published online March 23, 2018]. Ann Emerg Med. doi: 10.1016/j.annemergmed.2018.02.004