What's the Best Treatment for Gout Flares?

Global gout treatment guidelines tend to differ on which drug should be used as first-line therapy for gout flares.

According to the European League Against Rheumatism guidelines, colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, are the most effective first-line therapies for acute gout flares. Meanwhile, the American College of Rheumatology prefers allopurinol, though many patients of Asian descent who take it are at high risk for severe hypersensitivity reactions.

The Annals of Internal Medicine recently published a large, randomized, controlled trial that shows oral prednisolone is just as effective as indomethacin for analgesia in acute gout patients.

The researchers enrolled patients aged 18 years and older who presented to 4 emergency departments with arthritis symptoms consistent with gout.

The participants were randomized into either of the following groups:

· The indomethacin group received 50 mg of oral indomethacin 3 times a day and 6 tablets of oral placebo prednisolone once a day for 2 days, followed by halved doses for 3 days.

· The prednisolone group received 30 mg of oral prednisolone once a day and 2 tablets of placebo indomethacin 3 times a day for 2 days, followed by the same prednisolone dose and a halved placebo indomethacin dose for 2 days.

Both groups received 1 g of oral acetaminophen every 6 hours as needed.

Oral prednisolone and oral indomethacin were equally effective to treat pain at rest and with activity without serious adverse effects. These findings validate previous randomized, controlled trials, but they show lower rates of adverse effects associated with indomethacin.

Overall, the study results suggest that oral corticosteroids are an appropriate option alongside NSAIDs (eg, indomethacin) or colchicine. Notably, this research was statistically and methodologically more reliable than past studies, according to the researchers.

Steroids are a particularly well-suited alternative for patients who find NSAIDs and colchicine intolerable.

Although this study didn’t find any serious adverse events related to indomethacin, the researchers excluded high-risk patients with gastrointestinal bleed history, renal insufficiency, or unstable cardiovascular disease. Of note, patients with gout tend to be older patients at risk for serious gastrointestinal, renal, and cardiovascular complications.