This article is more than 5 years old. Information may no longer be current.

Oral prednisolone safe, effective first-line treatment for acute gout

A comparison between indomethacin and oral prednisolone therapies found that the treatments demonstrated similar clinically significant pain reduction for patients with acute gout.

Timothy Hudson Rainer, MD, at the emergency medicine academic unit at Cardiff University, United Kingdom, and colleagues, reported in the Annals of Internal Medicine that oral prednisolone should be considered a safe and effective initial treatment.

The study was fueled by the need for more evidence for acceptance of oral corticosteroids as a first-line therapy, they wrote.

"The evidence-based recommendations for the management of gout from the European League Against Rheumatism recommend nonsteroidal anti-inflammatory drugs (NSAIDs) and/or colchicine as first-line agents despite the recognized disadvantages association with these drugs," Rainer and colleagues said. "The British Society for Rheumatology and British Health Professionals in Rheumatology recommend using steroids as treatment for acute gout, but only in patients who are unable to tolerate NSAIDs or who are refractory to colchicine. The most recent American College of Rheumatology guideline on gout management recommends oral corticosteroids in addition to NSAIDs and colchicine as first-line options for treatment of acute gout, based on data from two small randomized, controlled trials."

The researchers conducted a multicenter, double-masked, randomized equivalence trial of patients who reported to one of four EDs in Hong Kong. The patients were all aged 18 years and older and presented with acute arthritis that suggested a diagnosis of gout.

Patients were randomly assigned to receive prednisolone or indomethacin for 5 days. Patients in the indomethacin group received 50 mg of oral indomethacin three times a day and six tablets of oral placebo prednisolone once a day for 2 days. This was followed by 25 mg of indomethacin three times a day and six tablets of placebo prednisolone once a day for three times a day. Patients in the prednisolone group received 30 mg of oral prednisolone once a day and two tablets of placebo indomethacin three times a day for 2 days. This was followed by 30 mg of oral prednisolone once a day and one tablet of placebo indomethacin three times a day for 3 days. Patients in both groups were prescribed oral paracetamol that could be taken, as needed, every 6 hours.

The study included 376 patients who met the inclusion criteria and completed the study.

Results showed that patients in both groups experienced clinically significant and equivalent reductions in mean pain scores.

In addition, no major adverse events were reported. More patients in the indomethacin group had minor adverse events during the ED phase.

The researchers also reported that patients who received indomethacin were more likely to follow-up with a general practitioner or outpatient clinic compared with patients who received prednisolone.

"For many years, NSAIDs and colchicine have been used as first-line treatments for acute gout," Rainer and colleagues wrote. "However, their use is limited in elderly adults and in patients with comorbid conditions (such as renal insufficiency or gastrointestinal disease) because of their potential adverse effects and drug interactions. Our study provides robust evidence that oral corticosteroids are as effective as treating pain and as acceptable to patients NSAIDs and that they should be considered as a first-line alternative to NSAIDs in the treatment of patients with acute gout." – by Chelsea Frajerman Pardes

Disclosures: Rainer reports grants from the Health and Health Services Research Grant Committee of the Hong Kong Government during the conduct of the study. Please see the study for a full list of all other authors' relevant financial disclosures.