Oral prednisolone offers pain relief similar to that provided by indomethacin in patients with acute gout, according to research from four Hong Kong emergency departments.
“There was no overall difference in change in pain score at any time point,” Dr. Timothy Hudson Rainer from Chinese University of Hong Kong told Reuters Health by email.
Both drugs worked equally well, he said, but there more minor adverse effects in the indomethacin group.
As reported in Annals of Internal Medicine, Dr. Rainer and colleagues compared the two drugs in a double-blind randomized trial of 416 patients with acute gout.
“When the study was first designed, steroids had very little place in national guidelines for the treatment of gout,” Dr. Rainer explained. “If they had any place then it was as a second-line treatment. It appeared that much more evidence was needed to convince expert reviewers and doctors in general. After the study started, there was some agreement from U.S. experts to include oral prednisolone as first line in national guidelines. But the same was not true elsewhere in the world.”
Both groups achieved similar clinically significant reductions in mean pain scores at rest and with activity during the two-week study.
During their time in the emergency department, about three times as many patients in the indomethacin group as in the prednisolone group experienced at least one adverse event (18.8 percent versus 6.3 percent). Events were generally minor and included dizziness, sleepiness, and nausea. Changes in joint redness and tenderness and patient satisfaction with analgesia were similar for the two treatment groups.
“We were surprised that in a further analysis there were no early clinical features to differentiate patients who would respond to the drugs from those patients who wouldn’t,” Dr. Rainer said. “We thought that some early predictors would be evident but they weren’t. This information was not presented in our paper due to limitations in space and word count by the publisher. However, we may write it up in another article.”
“Funding is needed for further studies to investigate predictors of responders, better strategies for prevention, and interventions to prevent the development of cardiovascular disease associated with inflammatory conditions such as gout,” Dr. Rainer said.
Dr. Richard Day from the University of New South Wales School of Medical Sciences, Darlinghurst, New South Wales, Australia, who has published numerous studies related to gout and its treatment, told Reuters Health by email, “A short course of prednisone, ie, four days as per this study, is as effective as indomethacin and safe. It is a good option in those with contraindications to indomethacin.”
“Many physicians would coprescribe proton pump inhibitors for the patients started on indomethacin,” he said. “It’s another relative negative for the choice of indomethacin versus prednisone. The main issue for the selection of prednisone is to be sure that it is gout and not septic arthritis that is being treated.”