Anti-inflammatory treatment of acute gouty arthritis

Acute gouty arthritis is characterised by acute and severe episodes triggered by

the precipitation of monosodium urate (MSU) crystals in the synovium of usually
peripheral joints. The most common joint affected is the first meta-tarsal
phalangeal joint. This deposition and precipitation event causes an acute
inflammatory reaction involving chemokines and the recruitment of neutrophils
to the synovium (Khanna & Fitzgerald 2015). The treatment of acute gouty
arthritis typically involves adequate treatment of pain and anti-inflammatory
therapy. The choice of anti-inflammatory therapy will be discussed here.
The following anti-inflammatory treatments are available for the treatment of
acute gout: NSAIDs, corticosteroids and colchicine. The purpose of these
medications is to reduce the inflammatory reaction that results in pain and joint
deformity. The recommendations of the American College of Rheumatology and
British Society of Rheumatology both state that NSAIDs, corticosteroids and oral
colchicine are all similarly effective in the treatment of acute gout. However, The
European League against Rheumatism (EULAR) recommends oral colchicine
and/or NSAIDs as first-line treatments for the treatment of acute attacks over
oral corticosteroids (Khanna & Fitzgerald 2015). The results of a recent
systematic review concluded that there is equivalent efficacy of NSAIDs and
corticosteroids with no head-to-head study comparing these with colchicine
(Khanna et. al. 2014).
The most commonly used NSAID in the treatment of acute gout is indomethacin
and dosing is usually 50mg orally every 8 hours until pain scores fall to an
acceptable level. NSAIDs are not advised for use in patients with previous history
of coronary artery disease, cerebrovascular disease, gastrointestinal bleeding,
and hepatic/renal impairment (Khanna et. al. 2014).
Corticosteroids, as previously mentioned, have similar efficacy to NSAIDs and
oral colchicine however should only be administered if septic arthritis has been
excluded. It may be delivered orally, intra-muscularly or intra-articularly in the
case of large joints. Commonly prescribed doses vary from 20-40mg oral daily in
a tapered dosing pattern (Khanna et. al. 2014).
It is recommended to begin colchicine at the lowest possible dose (1.2mg
followed by 0.6mg 1 hour later) and increasing until desired effect or restricted
by adverse effects (GI disturbance, thrombocytopaenia, leukopaenia,
granulocytopaenia etc.). A study comparing low dose colchicine with placebo
found no statistically significant difference in adverse effects and a significantly
decreased adverse effects profile compared to high-dose colchicine whilst
maintaining similar efficacy (Terkeltaub et. al. 2010). Colchicine is not
recommended for patients with renal/hepatic impairment due to the risk of acute
toxicity (Turner & Cooper 2015).

In the case of Mr RG, he was given an NSAID for his pain with prednisolone 30mg
orally. This is appropriate in the context of the available evidence. There is
currently no reliable trial data comparing the use of NSAIDs/corticosteroids and
colchicine. In clinical practice it remains that there is relative freedom in the
choice of anti-inflammatory medications for acute gout. With similar efficacy
between the three choices it is usual practice to delay more toxic medications
(colchicine) after others have proven inadequate. Care must also be taken in
considering the patients co-morbidities in choosing the most appropriate
therapy.
References
Khanna, P & FitzGerald, J 2015, Evolution of management of gout: a comparison
of recent guidelines, Current Opinion Rheumatology, vol. 24, no. 2, pg. 139146.
Khanna, P, Gladue, H, Singh, M, FitzGerald, J, Bae, S, Prakash, S, Kaldas, M,
Gogia, M, Berrocal, V, Townsend, W, Terkeltaub, R & Khanna, D 2014, Treatment
of acute gout: a systematic review, Seminars in Arthritis and Rheumatism, vol.
44, no. 1, pg. 31-38.
Terkeltaub, R, Furst, D, Bennett, K, Kook, K, Crockett, R & Davis, M 2010, High
versus low dosing of oral colchicine for early acute gout flare: Twenty-fourhour
outcome of the first multicenter, randomized, double-blind, placebo-controlled,
parallel-group, dose-comparison colchicine study, Arthritis & Rheumatism, vol.
62. no. 4, pg. 1060-1068.
Turner, J & Cooper, D 2015, Does colchicine improve pain in acute gout flare?,
Annals of Emergency Medicine, Published 24 April 2015.