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Corticosteroid Vs NSIDs In Acute Gouty Arthritis

It has been a long time, non-steroidal anti-inflammatory drugs have been the primary choice for acute gouty arthritis treatment. But now, corticosteroids are being considered to be the first choice substitute because these have milder side effects and the same approximate effectiveness.

Corticosteroid Vs NSIDs In Acute Gouty Arthritis
Acute Gouty Arthritis
Source picture: https://www.medicalacademic.co.za/orthopaedics/get-to-grips-with-gout/


Gouty arthritis is an inflammation of the joints caused by the deposition of monosodium urate crystals in synovial fluid and other tissues. The American College of Rheumatology (ACR) guidelines recommend giving pharmacological treatment for acute gouty arthritis in the first 24 hours. The treatment options recommended by the ACR and European League Against Rheumatism (EULAR) are oral corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), and colchicine.

Since colchicine often causes side effects such as diarrhea and kidney disorders, NSAIDs are the main choice to replace colchicine. The side effects of using NSAIDs, such as gastrointestinal bleeding and cardiovascular diseases, must be noted, especially for NSAIDs, which are not classified as selective cyclo-oxygenase-2 (COX-2) inhibitors (COXIBs). This should be pointed out because the average gout arthritis sufferers are old and often have comorbidities. According to AAFP, First-line therapy is indometacin 3 x 500 mg.

ACR recommendations dosages for the treatment of  acute gouty arthritis attacks are as follows:

1. Colchicine: 1.2 mg (first dose) followed by 0.6 mg the next 1 hour,
2. NSAID in full dose
3. Prednisolone: ​​0.5 mg/kg per day for 5-10 days or 2-5 days full dose and tapering off for 7-10 days.

Monotherapy with one of the three options above can be given in mild to moderate pain in one or several small joints or 1-2 large joints. Combination therapy is recommended for severe pain and large joints. The Combinations are colchicine with NSAIDs, colchicine with oral steroids, or intra-articular steroids with oral medications.

Steroids for the treatment of acute gouty arthritis can be given in oral, intra-articular, and intramuscular preparations. Intra-articular dosage is depending on the size of the joint and can be provided with or without oral steroids. Intra-articular steroid administration is recommended in acute attacks in 1-2 large joints. If this is not possible, oral steroids are the first choice. The dose for intramuscular is 60 mg triamcinolone acetone with the addition of oral steroids.

Rainer et al. (2016) compared treatment with prednisolone versus indomethacin in 376 patients with acute gouty arthritis. The parameter used is the pain scale. Oral prednisolone was found to have the same effectiveness as indometacin (p = 0.69). Minor side effects arose, more in the prednisolone group compared with indomethacin (10% vs. 6%, p = 0.001), but more researches were needed because patients with a history of gastrointestinal bleeding had been excluded in the study.

Janssens et al. (2008) in a randomized double-blind study compared oral prednisolone with naproxen in reducing pain in gouty arthritis. Gouty arthritis was diagnosed through synovial fluid analysis. This method is not commonly used and increases the risk of septic arthritis. The reduction in pain scale within 90 hours was not significantly different in the two groups, and only a few minor side effects were found. As with previous studies, a history of gastrointestinal bleeding and peptic ulcers was excluded. In both groups, the pain resolved in 3 weeks.

The first study comparing steroids and NSAIDs in gouty arthritis was conducted by Man et al. (2007) with a randomized trial comparing prednisolone with indometacin (which was also given a 75 mg intramuscular injection of diclofenac) and in each group combined with 1 gram of paracetamol. Pain reduction measured by the pain scale was found to be more in the oral steroid group than NSAIDs, where this difference is statistically significant (-2.9 mm vs. -1.7 mm, p - 0.0026). Side effects were more experienced by the indomethacin group (P <0.05), and the most frequently encountered were nausea, dyspepsia, heartburn, headaches, and gastrointestinal bleeding. In this study, no gastrointestinal bleeding was found in the steroid group. The recurrence rates in the two groups were not much different.

Furthermore, in the study of Man et al., Which combined paracetamol as adjunctive therapy for pain relief, paracetamol was found to be more needed in the steroid group. Within 14 days, an average of 10.3 grams and 6.4 grams were required in the steroid and NSAID groups. Pain reduction may be affected by paracetamol administration, but it may not be due to the difference of only 4 grams in 14 days.

ACR recommends oral steroids as second-line prophylactic therapy. The first line is giving uric acid-lowering drugs combined with low-dose colchicine (1-2 x 0.5 mg) or low-dose NSAIDs with or without proton pumping. The prophylactic dose of steroids (prednisolone) is <10 mg/day. There is no further research on the benefits and risks of pharmacological drugs for this prophylaxis.

Using steroids in gouty arthritis is still rare. In the United States, only 9% are found. In 3 studies that have been described found that oral steroids have the same effect as NSAIDs. So that steroid administration needs to be considered in patients with contraindications to NSAIDs such as kidney disorders.

Long-term steroids have a better anti-inflammatory effect compared to NSAIDs but have greater side effects. Giving steroids in the short term (1 week) tends to be safe. However, in patients with certain conditions such as uncontrolled diabetes mellitus, immunocompromised, active peptic ulcer, osteoporosis, and herpes infections need to consider the benefits and risks, even if given for a short time.

References
1. Khanna D, Khanna PP, Fitzgerald JD, Singh MK, Bae S, Neogi T. 2012 American College of Rheumatology Guidelines for Management of Gout. Part 2: Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. Arthritis care & research, 2012;64(10):1447-1461
2. Richette P, Doherty M, Pascual E, Barskova V, Becce F, Castaneda-Sanabria J, et al. 2016 updated EULAR evidence-based recommendation for the management of gout. Ann Rheum Dis, 2016;0:1-14
3. Prasad S, Ewigman B. Acute gout: oral steroids work as well as NSAIDs. Priority updates from the research literature, 2008;57(10):655-657
4. Hainer BL, Matheson E Wilkes RT. Diagnosis, treatment, and prevention of gout. Am Fam Physician, 2014;90(12):831-836
5. Rainer TH, Cheng CH, Janssens HJEM, Man SY, Tam LS, Choi YF, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med, 2016;164:464-471
6. Janssens HJ, Janssen M, van de L isdonk EH, van Riel PL, van Weel C. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomized equivalence trial. Lancet, 2008;371:1854-1860
7. Man CY, Cheung ITF, Cameron PA, Rainer TH. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute gout-like arthritis: a double-blind, randomized, controlled trial. Ann Emerg Med, 2007; 49:670-677
8. Krishnan E, Lienesch D, Kwoh CK. Gout in ambulatory care settings in the United States. J Rheumatol, 2008;35:498-501
9. Becker DE. Basic and clinical pharmacology of glucocorticosteroids. Anesth prog, 2013;60(1):25-31

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