Naproxen better first-line gout option than colchicine in primary care
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Although there is no significant difference between naproxen and low-dose colchicine in terms of improvements in pain intensity among patients with gout flare, naproxen causes fewer side effects, making it the superior first-line option for gout flares in primary care, according to findings published in Annals of the Rheumatic Diseases.
“Numerous randomized trials demonstrate that NSAIDs treat gout flares effectively,” Edward Roddy, DM, FRCP, of Keele University, in the United Kingdom, and colleagues wrote. “However, side effects are frequent and can be life-threatening. NSAIDs are commonly used in all age groups: Three-quarters of NSAID prescriptions for gout flares in the UK. in 2001-2004 were for diclofenac or indomethacin, two of the most toxic NSAIDs. Naproxen is associated with lower vascular risk than other NSAIDs and is as effective as oral prednisolone for gout flares.”
“High-dose colchicine is effective but commonly causes gastrointestinal side effects,” they added. “Lower doses are as effective but better tolerated. The recommended ‘low-dose’ regimen in the UK is 500 [µg] two to four times per day, however, the effectiveness and tolerability of this dose have never been evaluated. A direct comparison of an NSAID and low-dose colchicine is needed to inform choice for patients and practitioners.”
To analyze the effectiveness and safety of naproxen compared with low-dose colchicine for gout flares in primary care, Roddy and colleagues conducted an open-label randomized trial of 399 adults from 100 general practices throughout England. Participants were randomly assigned to one of two treatment groups, with 200 receiving 750 mg of naproxen immediately followed by 250 mg of the drug every 8 hours for 7 days. The remaining 199 were treated with 500 µg of colchicine three times per day for 4 days.
The primary outcome was the change from baseline in worst pain intensity in the past 24 hours, using the 0 to 10 numeric rating scale, measured daily through the first 7 days. Mean change from baseline was compared between groups. A total of 349 participants completed the primary outcome data at day 7.
According to the researchers, there was no significant difference between the groups in terms of average changes in pain scores throughout the 7-day period. Among participants in the colchicine group, compared with those treated with naproxen, the mean difference was –0.18 (95% CI, –0.53 to 0.17).
However, during the 7-day treatment period, diarrhea was more common among those treated with colchicine compared with the naproxen group, by 45.9% to 20% (OR = 3.31; 2.01-5.44). This was also true of headaches, with 20.5% in the colchicine group and 10.7% among those treated with naproxen (OR = 1.92; 95% CI, 1.03-3.55). Constipation was less common in the colchicine group, at 4.8% compared with 19.3% in the naproxen group (OR = 0.24; 95% CI, 0.11-0.54).
“NSAIDs and colchicine are not the only drugs used to treat gout flares,” Roddy and colleagues wrote. “The American College of Physicians recommends corticosteroids as first-line treatment, whereas other guidelines advise being guided by comorbidities, contraindications, previous response and the pattern of joint involvement. While randomized trials have compared NSAIDs and prednisolone, future research should compare the effectiveness and safety of colchicine and corticosteroids, particularly in patients with contraindications to NSAIDs.”
They added, “We found little difference in pain reduction between naproxen and low-dose colchicine, but naproxen was associated with fewer side effects, less analgesic use and slightly lower costs, suggesting that, in the absence of contraindications, naproxen should be used ahead of low-dose colchicine to treat gout flares in primary care.” – by Jason Laday
Disclosure: The researchers no relevant financial disclosures.
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