Q. If you’re not experienced in this technique and a rheumatologist or other specialist is not immediately available to perform it for you, what would you do then?
Because Mrs. Jones’s heart failure is stable and mild, you can consider a 5-day course of prednisolone together with a proton pump inhibitor to reduce the risk of GI toxicity while monitoring her heart failure and INR carefully. While the dose of prednisolone used in the trials was 30 to 35 mg, you are reluctant to use a dose this high with this patient, and so opt to use a lower dose of 15 mg daily and review her progress in 24 hours. The next day her symptoms are improved and Mrs. Jones continues the prednisolone for the next 4 days.
So where do we go from here?
Although anti-inflammatories, colchicine, and intra-articular and systemic corticosteroids have been mainstays of treatment for acute gout for years, evidence to guide your therapeutic choices is limited. NSAIDs are a reasonable first option, provided there are no contraindications. However, as Case 2 illustrates, when NSAIDs are contraindicated the available evidence provides only limited guidance for treatment choices.
While colchicine has demonstrated efficacy at the standard dosage of 1 mg orally followed by 0.5 mg every 2 hours, the unacceptably high level of GI side effects, together with concerns about more serious toxicity, limits its usefulness.12 No trials have examined the effectiveness and safety of lower doses. Intra-articular corticosteroids may be effective, but this has not been tested in an RCT.
One trial found that oral prednisolone 35 mg daily provided equivalent relief to NSAIDs, and this is another treatment option.9 However, it is unclear whether lower doses of oral corticosteroids might be similarly effective with reduced risks. The bottom line is that more high-quality clinical trials are needed to determine the optimum therapy for acute gout.
Correspondence
Tania Winzenberg, MBBS, Menzies Research Institute, Private Bag 23, Hobart, Tasmania, Australia 7001; Tania.Winzenberg@utas.edu.au