COX-2 Inhibitors Best Traditional NSAIDS for Acute Gout

In patients with acute gout, cyclo-oxygenase-2 (COX-2) inhibitors, especially etoricoxib (Arcoxia, Merck & Co.), may result in a greater clinical response than traditional non-steroidal anti-inflammatory drugs (NSAIDs), according to a study published in BMJ Open.

“COX-2 inhibitors are comparable to traditional NSAIDs with regard to pain relief, but are preferable to traditional NSAIDs in terms of clinical symptoms and investigator’s global assessment of response,” wrote the authors, led by Xiaofeng Zeng, M.D., of Peking Union Medical College & Chinese Academy of Medical Science in Beijing, China.

There is an increasing trend in the burden of gout, with a global prevalence of up to 10 percent. The 2006 and 2016 European League Against Rheumatism recommendations and American College of Rheumatology guidelines recommend NSAIDs as the first-line option for the management of acute gout. However, studies suggest that monosodium urate microcrystals, which cause an inflammatory response in gout, induce the production of COX-2 in monocytes. The efficacy of COX-2 inhibitors is comparable to that of traditional NSAIDs, but COX-2 inhibitors have fewer adverse effects, particularly gastrointestinal adverse effects. Due to the increasing use of COX-2 inhibitors and the large number of recent trials, evaluation of the comparative efficacy of various COX-2 inhibitors is necessary.

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In this systematic review and metanalysis of 24 studies,the researchers assessed the comparative efficacy of traditional NSAIDs, indomethac and indiclofenac, and the COX-2 inhibitors etoricoxib, celecoxib and meloxicam in patients with acute gout. The main outcome measures were mean change in pain Visual Analogue Scale (VAS) score and five-point Likert scale score on days two to eight.

In terms of pain VAS scores and clinical improvement, etoricoxib 120 mg four times a day showed an advantage over celecoxib 200 mg three times a day. With regard to Likert scores, etoricoxib showed an advantage over meloxicam, and all COX-2 inhibitors showed better efficacy than non-selective NSAIDs. However, subgroup analysis showed no significant difference between the two groups of drugs.

“Etoricoxib may be the best option when COX-2 inhibitors are indicated,” the authors wrote.

While colchicine and corticosteroids are also the main therapeutic options for acute gout flares, these drugs were not included in this meta-analysis.

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REFERENCE

Mengtao Li, Chen Yu, Xiaofeng Zeng. Comparative efficacy of traditional non-selective NSAIDs and selective cyclo-oxygenase-2 inhibitors in patients with acute gout: a systematic review and meta-analysis.BMJ Open.September 10, 2020. doi: 10.1136/bmjopen-2019-036748