The corticosteroid drug prednisolone is as effective at treating gout arthritis as naproxen, a conventional treatment. Prednisolone could thus be used to treat the condition in place of conventional treatments that can cause gastrointestinal, renal, and cardiovascular complications. These are the conclusions of authors of an Article in this week’s edition of The Lancet.
Gout is a painful inflammatory arthritis with a sudden onset and a tendency to recur. The arthritis is caused by monosodium urate crystals in the joint. To diagnose gout, these crystals can be identified microscopically in the joint fluid or in tophi – knobbly deposits of this crystallised urate salt under the skin. The conventional drugs for arthritis are colchicine and non-steroidal anti-inflammatory drugs (NSAIDs). Colchicine is the most longstanding treatment, but its use has declined because of its narrow therapeutic window, its disadvantage in the case of renal failure and the availability of NSAIDs. NSAIDs are now the first choice of drug treatment, despite their gastrointestinal and cardiovascular risks, which are often seen in gout patients. Dr Hein Janssens, Radbound University Nijmegen Medical Centre and the Rijnstate Hospital, Arnhem, the Netherlands, and colleagues investigated the effectiveness of prednisolone and the NSAID naproxen, in primary care.
In a randomised clinical trial, 120 primary-care patients with gout confirmed by presence of monosodium urate crystals were assigned to receive either prednisolone (35 mg once a day, 60 patients), or the naproxen (500 mg twice a day, 60 patients). The researchers measured pain using a visual analogue scale from 0 mm (absence of pain) to 100 mm (most severe pain ever experienced). They found after 90 h the reduction in the pain score was between 62 and 17 mm for prednisolone, and 59 to 13 mm for naproxen, in almost the same pattern, suggesting equivalence. Adverse effects were similar between groups, minor, and resolved by three week follow-up.
The authors conclude that prednisolone was, in this trial, clinically equivalent to naproxen in the treatment of gout. They say: “ In addition to better safety, the direct drug costs would also be less if systemic corticosteroids, such as prednisolone, were the first-line drug choice. In the context of economic benefits, the additional costs of gastroprotective drugs added to NSAID-treatment, should also be taken into account. In conclusion, the present study provides a strong argument to consider prednisolone as a first treatment option in patients with gout.”
In an accompanying Comment, Dr Timothy Rainer and Dr Colin Graham, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, say that the results of the study may need to be repeated in larger trials to convince physicians to change clinical practice. They conclude: “Nevertheless Janssens’ trial will go some way to satisfy both rheumatological purists and front-line pragmatists that short-term oral corticosteroids are as equally effective as NSAIDs in the initial treatment of acute gout and gout-like syndrome.”
Dr Hein Janssens, Radbound University Nijmegen Medical Centre, Netherlands T) +31 (0) 6 20441758 E) H.Janssens@hag.umcn.nl
Dr Timothy Rainer and Dr Colin Graham, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong T) +852 26321034 E) thrainer@cuhk.edu.hk
http://multimedia.thelancet.com/pdf/press/Gout.pdf
Journal
The Lancet