For acute gout corticosteroids look safer than NSAIDs

For the treatment of acute gout, corticosteroids maybe as effective as nonsteroidal anti-inflammatory drugs but with fewer side effects based on findings from a metaanalysis of six randomized, controlled trials.

There is insufficient information to determine the comparative efficacy of corticosteroids and NSAID(s) to treat acute gout, while corticosteroids appear to have a more favorable safety profile for selective (adverse events).

Two previous systematic reviews also suggested that corticosteroids maybe therapeutically equivalent to but safer than NSAIDs, but both were based on a very small number of available studies and were hampered by statistical between-trial heterogeneity. The meta-analysis of six trials included a total of 817 patients. The trials had a mean followup of 15 days. Two trials were in hospitalized patients, two involved patients in the emergency department, one included outpatients, and one did not disclose the location of clinical presentation.

Mean age of participants ranged from 44 years to 65.9 years, and the proportion of men ranged from 70 percent to 100 percent.

With respect to pain scores, the researchers found no significant difference between corticosteroids and NSAIDs within seven days of treatment based on moderate-quality evidence from two randomized, controlled trials (RCTs) involving 534 patients (standardized mean difference = -0.09; 95 percent confidence interval, -0.26-0.08). There was also no difference between the two on pain after seven or more days based on low-quality evidence from two RCTs of 506 patents (SMD = 0.32; 95 percent CL, -.27-0.92). There was no evidence of statistical heterogeneity in the short-term trials, but there was evidence of significant heterogeneity in trials measuring treatment effects for seven days or longer (P= .01; I2 [heterogeneity]=85 percent).

Two RCTs of 173 patients gave low-quality evidence to show no difference between corticosteroids and NSAIDs in the rate of treatment response in the short term(relative risk, 1.07; 95 percent CI, 0.80-1.44; moderate heterogeneity P=15,12=53 percent). One long-term study of the rate of treatment response provided similar results. There were also no between group differences in joint swelling, erythema, tenderness, or activity limitations.

The investigators discovered that patients who took corticosteroids had a lower risk of indigestion in three RCTs with 526 patients (RR, 0.50;95 percent CI,0.27-0.92), nausea in three RCTs of 566 patients (RR, 0.25; 95 percent CI, 0.11-0.54) and vomiting in two RCTs totaling 506 patients (RR,0.11;95 percent CI, 0.02-0.56).

This meta-analysis was limited by the small number of clinical trials available for inclusion, which prevented the estimate of a number of outcomes and subgroup analyses. There was also a high risk of bias in many of the studies. Only half of the studies confirmed the diagnosis of gout by the presence of monosodium urate crystals within joint spaces. No studies reported on the effects of treatment on kidney function or injury.

The authors disclosed no source of funding or financial relationships.