The management of the gout flare was one of the topics covered in a seminar on Gout published online in the Lancet in March 2021. According to the authors (Prof Nicola Dalbeth, Prof Anna Gosling, Prof Abhishek Abhishek, Dr Angelo Gaffo et al.) the major priorities in the management of the gout flare are pain control and suppression of joint inflammation.
“Early administration of anti-inflammatory treatment is recommended to rapidly suppress joint pain and inflammation. Head-to-head clinical trials comparing oral agents with different mechanisms of action have shown equivalent efficacy between oral prednisolone, non-steroidal anti-inflammatory drugs (non-selective or COX-2-selective), and low-dose colchicine for gout flare management.”
The studies in question indicated that oral corticosteroids might have a slightly better safety profile than non-steroidal anti-inflammatory drugs and that fewer side-effects are caused by non-steroidal anti-inflammatory drugs than by low-dose colchicine, the researchers explained. “Low-dose colchicine (1.0-1.2mg immediately, followed by 0.5-0.6mg after 1 hour) leads to fewer side-effects compared with high-dose colchicine (4.8mg administered over 6 hours) with similar efficacy and high-dose colchicine is not recommended,” Prof Dalbeth et al. continued.
CHOOSING THE RIGHT MEDICATION
“First-line therapy for acute gout is nonsteroidal anti-inflammatory drugs or corticosteroids, depending on comorbidities; colchicine is second-line therapy,” said Dr Aaron Eggebeen (University of Pittsburgh Arthritis Institute).
“For patients who have had recurrent gout flares, the choice of agent is often determined by patient preference based on previous experience of efficacy and adverse events. For many patients, comorbidities and concomitant medications also influence the choice of agent.” Suggesting examples the authors said, “non-steroidal anti-inflammatory drugs are avoided if there is concomitant kidney disease, cardiac disease, peptic ulcer disease, and anticoagulant use. High-dose oral prednisone is avoided in the setting of infection, fluid overload, or diabetes. Colchicine toxicity can occur in patients with severe kidney disease, severe liver disease, and concomitant use of strong P-glycoprotein 1 (ABCB1) inhibitors, CYP3A4 inhibitors, or both (e.g. ciclosporin, ketoconazole, clarithromycin, and verapamil). For a single inflamed joint intra-articular corticosteroids might be the preferred strategy. Intra-articular, intramuscular, or intravenous corticosteroids are also an option for patients experiencing a gout flare who are unable to take oral medications.”
The study found that consistent with the central role of the NLRP3 inflammasome activation in the acute inflammatory response to monosodium urate crystals, IL-1 inhibitors are also effective for gout flare management. “A single subcutaneous injection of canakinumab 150mg provided better pain and inflammation relief and reduced the risk of new flares than did treatment with intramuscular triamcinolone acetonide 40mg, but caused higher rates of adverse events, including serious infections. “Anakinra 100mg subcutaneously daily for five days has an efficacy and safety profile similar to first-line oral anti-inflammatory therapies. IL-1 inhibitors are generally reserved for patients who have intolerable side-effects or have contra-indications to first-line anti-inflammatory therapy.”
Research into non-pharmacological therapies like the application of ice packs on the inflamed joints indicated some analgesia was found. “Supportive care including rest, mobility assistance, and adequate nutrition and hydration are important for patients experiencing severe joint pain.
“Although the focus of the gout flare consultation is acute symptom management, this interaction represents an important opportunity to ensure patient understanding about gout and optimise long-term gout management. All patients presenting with a gout flare should be informed about the availability of long-term, urate-lowering therapy to address the underlying cause of the disease and prevent future flares and joint damage,” the authors advised.