Design the therapy to fit the patient
The study cited above demonstrates that there is no real difference, either in efficacy or safety, between corticosteroids and NSAIDs in the treatment of gout. In theory, that would seem to mean that you could feel equally comfortable prescribing either therapy. But in clinical practice, characteristics of individual patients and the profile of each class of drugs will influence your choice. The following cases illustrate this point. These cases discuss the initial treatment of acute gout, but of course in clinical practice you would go on to consider ongoing prophylactic treatment.
Mr. Peters is a 53-year-old man with a body mass index of 29. He is usually well and not on any medication. He limps into your office one day, complaining of excruciating pain in his left great toe that started suddenly the night before. He’d had a bad night, with pain so severe he couldn’t even tolerate the pressure of the bed sheet on his foot. A dose of acetaminophen failed to control the pain. He has never experienced anything like it.
You look at his foot, and find a swollen, erythematous first metatarsophalangeal joint. On the basis of this classic presentation, you make a provisional diagnosis of gout.
Q. What immediate treatment do you choose?
You consider colchicine, but decide against it because of its side effect profile. Mr. Peters has no contraindication for NSAIDs, so you start him on diclofenac 50 mg orally, 3 times a day. You are aware that NSAIDs can have adverse effects in some patients. If Mr. Peters develops these or fails to improve quickly on diclofenac, you will consider switching him to intra-articular or systemic corticosteroids. Therefore, you ask him to check back with you in 48 hours regarding his progress. At this review, you find his symptoms are settling well, with no adverse effects.
CASE 2
Mrs. Jones, age 81, arrives in your waiting room with an acutely painful, red, and swollen right index finger. Her condition makes it very difficult for her to bathe and prepare meals, a serious problem because she lives alone. She has hypertension, chronic atrial fibrillation, and chronic mild heart failure that has been stable for more than a year.
Mrs. Jones takes warfarin 4 mg daily because of her atrial fibrillation. Her international normalized ratio (INR) has been stable on this dose for the last 6 months. Mrs. Jones also takes perindopril 5 mg and hydrochlorothiazide 6 mg daily for her heart failure and hypertension. Her renal function is normal. You notice that in addition to the inflamed proximal interphalangeal joint of the index finger of the right hand, Mrs. Jones has swelling and what appears to be a tophus over the distal interphalangeal joint of the third finger, which suggests that she has gout. You realize that the thiazide diuretics may have precipitated this problem and that possibility will need to be addressed, but in the short term you are concerned about managing her pain and restoring her hand function.
Q. What treatment do you consider?
There are many reasons why you are extremely reluctant to use NSAIDs. Mrs. Jones’s age and the warfarin she takes create an unacceptably high risk of GI bleeding. Other side effects of NSAIDs, including hypertension and fluid retention, could aggravate her cardiac failure. You are also reluctant to use colchicine at the recommended high dosage for acute gout, because the GI effects associated with this drug may further incapacitate Mrs. Jones, and because the risk of dehydration with or without renal failure is particularly serious in an elderly woman.
You could consider a lower dose of colchicine, but the evidence for effectiveness and rapid onset of action at lower doses is weak and information on the frequency of GI effects at lower doses is not available. While a short course of oral corticosteroids is a possibility, these drugs also carry a risk of GI bleeding when used in combination with warfarin and might worsen her cardiac failure.
A steroid injection is worth considering. No RCTs have examined the effectiveness and safety of intra-articular corticosteroids for gout, but an uncontrolled trial of intra-articular triamcinolone acetonide (10 mg to the knee and 8 mg into small joints) demonstrated pain relief within 48 hours in all 19 patients receiving this treatment.4,11 Further, there is evidence that intra-articular corticosteroids are effective in other inflammatory joint conditions. Intra-articular injection of a corticosteroid carries a small risk of joint hemorrhage in a patient taking warfarin and might be painful when administered into the finger, but if the injection is done carefully with a small needle, this seems to be the safest option. You decide to explain the risks and benefits of the different strategies for treating gout, and recommend a local corticosteroid injection.