Fewer Withdrawals from Gout Rx with COX Inhibitors and Steroids

Four trials of moderate-quality evidence found no significant improvement in pain control in acute gout with NSAIDs vs COX inhibitors. But there was evidence that patients stopped NSAIDs early because of adverse events.

Oral NSAIDs are recommended by several gout guidelines as part of acute gout management.¹ However, the authors of this article say that NSAIDs were associated with more withdrawal from treatment, and they weren't significantly effective in managing gout pain when compared with cyclooxygenase inhibitors and glucocorticoids.

The American College of Rheumatology (ACR), British Society of Rheumatology (BSR), Dutch College of General Practitioners (DCGP), Multinational Evidence, Exchange and Expertise Initiative (3E), European League Against Rheumatism (EULAR), and Japanese Society of Gout and Nucleic Acid Metabolism (JSGNM) all list NSAIDs in first-line treatment for acute gout attacks. Only BSR also recommends coxibs as first line, and only ACR recommends corticosteroids as first line. DCGP recommends corticosteroids only after NSAIDs and colchicine.¹

The authors of this article summarized a recent Cochrane review, which compared the effectiveness of NSAIDs with:

Coxibs
Colchicine
Glucocorticosteroids (systemic and intra-articular)
IL-1 inhibitors
Combination therapy, and non-pharmaceutical treatments

The medications in the review were:

NSAIDS
Diclofenac
Etodolac
Flufenamic acid
Flurbiprofen
Ketoraolac
Ketoprofen
Meclofenamate
Meloxicam
Nimesulide
Phenylbutazone

Cyclooxygenase inhibitors:
Etoricoxib
Celecoxib
Lumiracoxib

Four trials of moderate-quality evidence (974 patients) that evaluated pain scores and withdrawal rates found there was no significant improvement in pain control in acute gout with NSAIDs compared with cyclooxygenase inhibitors. There was, however, evidence that patients stopped NSAID treatment early because of adverse events compared with cyclooxygenase inhibitor treatment.

Two trials of moderate-quality evidence (201 subjects) also found no significant improvement in gout pain reduction with NSAIDs, compared with glucorticosteroids. One trial of low-quality compared NSAIDs with rilonacept, an IL-1 inhibitor, finding that NSAIDs provided better gout pain relieve in this instance. None of these three trials showed evidence of early discontinuation of NSAID treatment due to adverse events.

A review published in June 2015 in Clinical Rheumatology had similar findings to the four moderate-quality trials regarding early cessation of NSAID treatment.² The authors found six trials (851 patients) that compared etoricoxib with indomethacin and diclofenac. The conclusion was that the patients were able to tolerate etoricoxib better than either NSAID.

More study comparing various gout treatments, including a direct comparison of cyclooxygenase inhibitors and glucorticosteroids in relieving acute gout pain, is required, the researchers concluded.

References:

11. Wise E, Khanna PP. The impact of gout guidelines. Current Opinion in Rheumatology. 2015;27:225–230 doi:10.1097/BOR.

2. Zhang S, Zhang Y, Liu P, et al. Efficacy and safety of etoricoxib compared with NSAIDs in acute gout: a systematic review and a meta-analysis. 2015. doi: 10.1007/s10067-015-2991-1