Optimisation of the treatment of acute gout

Most of the drugs prescribed to treat acute gouty attacks were used before the introduction of modern clinical trials. Thus, there are few well-design ed studies available to evaluate these drugs. Nevertheless, worldwide clini cal experience supports the use of most nonsteroidal anti-inflammatory drug s (NSAIDs), colchicine and corticosteroids in the treatment of acute gout. Colchicine has been widely used but toxicity, especially gastrointestinal a dverse effects, are a major concern. Therapeutic regimens involving hourly or 2-hourly administration were based on the short initial half-life of col chicine in plasma. Other therapy schedules, such as early 8-hourly administ ration, may be equally effective and have fewer adverse effects. Unfortunat ely, comparative studies to investigate this have not been performed. Colch icine should not be prescribed to patients with either severe renal insuffi ciency or combined hepatic-renal insufficiency. Doses should be halved in p atients with moderate renal function impairment. NSAIDs are the most widely prescribed drugs in the treatment of acute gout. Few comparative data are available, but any of the most potent NSAIDs are probably useful in the control of pain and inflammatory signs of acute gout y arthritis. Pharmacokinetic properties should be taken into account when s electing an NSAID for the treatment of gout, as rapid absorption and a shor t half-life may help to avoid accumulation in patients with subclinical ren al function impairment. Comorbidities should always be kept in mind when pr escribing NSAIDs. Patients with previous or recent gastrointestinal bleedin g, those receiving anticoagulant therapy or with haemorrhage diathesis, and those with renal insufficiency are at risk of developing severe adverse ef fects from NSAID administration. Corticosteroids are probably a reasonable choice for patients in whom colch icine and NSAIDs may be hazardous or for those with a history of previous i ntolerance to these drugs. Few trials using prednisone, prednisolone or tri amcinolone acetonide are available, and dosages are prescribed following em pirical data. Corticotropin has also been used to treat acute gout. Althoug h it has been proven to be as effective as other corticosteroids or indomet hacin, the need for multiple doses, parenteral administration and the high cost are major limitations for its use. Currently, the choice of a drug for the treatment of acute gout will depend on the balance between its efficacy and the potential adverse effects in a particular patient.