OBJECTIVE: Nonsteroidal antiinflammatory drugs (NSAID) are used as first-line agents to treat acute gout. Recent trials suggest a possible first-line role for corticosteroids.
METHODS: We conducted a metaanalysis of randomized controlled trials (RCT) evaluating corticosteroid versus NSAID therapy (nonselective and selective) as treatment for acute gout. MEDLINE, EMBASE, and CENTRAL were systematically searched through August 2016. Outcomes included pain, bleeding, joint swelling, erythema, tenderness, activity limitation, response to therapy, quality of life, time to resolution, supplementary analgesics, and adverse events. Evidence quality was summarized using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.
RESULTS: Six eligible trials (817 patients) were identified. The mean study followup was 15 days (range 4-30). Risks of bias were generally low. In low- to moderate-quality evidence, corticosteroids did not have different effects on pain score at < 7 days [standardized mean difference (SMD) -0.09, 95% CI -0.26 to 0.08] or at = 7 days (SMD 0.32, 95% CI -0.27 to 0.92) when compared with NSAID. There was no evidence of different risks of gastrointestinal bleeding [relative risk (RR) 0.09, 95% CI 0.01-1.67]. There was no evidence of different responses to therapy on pain at < 7 days (RR 1.07, 95% CI 0.80-1.44) and = 7 days, time to disease resolution, or number of supplementary analgesics used (MD 2.10 drugs, 95% CI -1.01 to 5.21). There was a lower risk of indigestion (RR 0.50, 95% CI 0.27-0.92), nausea (RR 0.25, 95% CI 0.11-0.54), and vomiting (RR 0.11, 95% CI 0.02-0.56) with corticosteroid therapy.
CONCLUSION: There is no evidence that corticosteroids and NSAID have different efficacy in managing pain in acute gout, but corticosteroids appear to have a more favorable safety profile for selected adverse events analyzed in existing RCT.
This is further support for use of corticosteroids in management of acute gout. It's is confirmation of equal efficacy compared to NSAID treatment but with less toxicity. It's valuable information for those who treat acute gout in patients with co-morbidities.
This is a well-designed meta-analysis. Given that the first-line medication for acute gout is NSAIDs in Japan, these results might change our practice. However, I am unclear whether corticosteroid might mask other rheumatic disease because it is sometimes difficult to differentiate acute gout from other rheumatic disease. Furthermore, short-term adverse effects of corticosteroid should be evaluated more extensively.
This meta-analysis confirms the efficacy and safety of corticosteroids in the management of an acute attack of gout. Corticosteroids are as effective as and possibly less toxic than non-steroidal anti-inflammatory drugs for this indication.