Systematic Review Updates Guidance on Gout Alternatives

March 5, 2014
Rita Baron-Faust

Updating the evidence on gout treatment, a systematic review assesses how to offer the best for gout patients while keeping their comorbidities in mind.

Khanna PP, Gladue HS, Singh MK, et al, Treatment of acute gout: A systematic review,Seminars in Arthritis and Rheumatism, http://dx.doi.org/0.1016/j.semarthrit.2014.02.003

This systematic review of randomized, controlled clinical trials (RCTs), intended to update information gathered to support the 2012 American College of Rheumatology guidelines on gout, begins with an acknowledgment that comorbidities mandate personalizing gout treatment. It then proceeds to define the options in detail.

The review of 30 RCTs of drug and non-drug gout treatments, conducted mostly among men in their mid-50s, found that medical options including non-steroidal anti-inflammatory drugs (NSAIDS), both non-selective and COX-2 inhibitors, as well as colchicines and corticosteroids, all effectively relieve the severe pain and swelling of acute gout attacks. The task is to find the best option for a particular patient. 

For example, in gout patients refractory to (or who can’t take) NSAIDs, colchicine, or corticosteroids, the IL-1beta inhibitory antibody canakinumab can be used as an off-label alternative, the authors say.

The review of pharmacologic and non-pharmacologic treatments included other IL-1 inhibitors, adrenocorticotropic hormone (ACTH), as well as topical ice and Chinese herbal supplements.

Among the findings:

•  Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs; the RCTs support oral and intramuscular use for acute gout.
•  Among the NSAIDs, but high-dose celecoxib (400-800 mg) had effects similar to indomethacin, but lower doses did not.•Oral colchicine was effective against pain if taken within 12 hours of an attack.
•  Overall, ACTH was an effective treatment for acute gout, providing faster pain relief than indomethacin with effects similar to those of intramuscular triamcinolone acetonide.
•  Among the IL-1beta inhibitors, canakinumab was as effective as intramuscular triamcinolone acetate. Rilonacept was not as effective in acute attacks.
•  As to non-drug treatments, topical ice provided additional relief when used alongside corticosteroids and colchicine. One randomized trial showed a traditional Chinese herb for joint inflammation, the Simiao pill, more effective than indomethacin at one week, while another found Danggui-Nian-Tong-Tang (DGNTT) not effective at all.