Gouty arthritis, acute NSAIDs

FIGURE 1-1. Treatment algorithm for acute gouty arthritis. (NSAID, nonsteroidal antiinflammatory drug.)... 

Corticosteroids may be used to treat acute attacks of gouty arthritis, but they are reserved primarily for patients with a contraindication or who are unresponsive to NSAID or colchicine therapy. Patients with multiple-joint involvement may also benefit. 

The prototypes of this large class of NSAIDs are in-domethacin and ibuprofen. These drugs are indicated for the relief of acute and chronic rheumatoid arthritis and osteoarthritis. In addition, a number of drugs of this class are also useful in ankylosing spondylitis, acute gouty arthritis, bursitis, and tendinitis. 

Indomethacin (Indocin) is used in the treatment of acute gouty arthritis, rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis. It is not recommended for use as a simple analgesic or antipyretic because of its potential for toxicity. While indomethacin inhibits both COX-1 and COX-2, it is moderately selective for COX-1. It produces more CNS side effects than most of the other NSAIDs. Severe headache occurs in 25 to 50% of patients vertigo, confusion, and psychological disturbances occur with some regularity. GI symptoms also are more frequent and severe than with most other... 

Although colchicine is more specific in gout than the NSAIDs, NSAIDs (eg, indomethacin and other NSAIDs [except aspirin]) have replaced it in the treatment of acute gout because of the troublesome diarrhea sometimes associated with colchicine therapy. Colchicine is now used for the prophylaxis of recurrent episodes of gouty arthritis, is effective in preventing attacks of acute Mediterranean fever, and may have a mild beneficial effect in sarcoid arthritis and in hepatic cirrhosis. Although it can be given intravenously, this route should be used cautiously because of increased bone marrow toxicity. 

Indomethacin This NSAID is more potent than aspirin as an antiinflammatory agent, but it is inferior to the salicylates at doses tolerated by rheumatoid arthritic patients. In certain instances, however (for example, with acute gouty arthritis, ankylosing spondylitis, and osteoarthritis of the hip), indomethacin is more effective in relieving inflammation than is aspirin or any of the other NSAIDs. 

This is an alkaloid derived from the autumn crocus (Colchicum). Colchicine rapidly relieves the pain and inflammation of an acute attack of gout. Such swift relief is considered to confirm the diagnosis because non-gouty arthritis is unaffected, though failure does not prove the patient is free of gout. It is most effective if given within 24 h of onset and is useful in patients in whom NSAIDs are contraindicated. It is also used in recurrent hereditary polyserositis (Familial Mediterranean Fever) when it may prevent attacks and the development of amyloid. The t) is 1 h. 

Acute gouty arthritis may be treated effectively with short courses of high-dose nonacetylated nonsteroidal antiinflammatory drugs (NSAIDs) or colchicine. 

Acute attacks of gouty arthritis may be treated successfuhy with colchicine or any of a variety of nonsteroidal anti-inflammatory drugs (NSAIDs) (Fig. 91-2). 

Indomethacin is as effective as colchicine in the treatment of acute gouty arthritis. Because acute gastrointestinal toxicity occurs far less frequently with indomethacin than with colchicine, it is preferred. Side effects imique to indomethacin include headache and dizziness. All NSAIDs have been implicated in the cause of gastric ulceration and bleeding, but with short-term therapy, this is not likely. 

Corticosteroids may be used to treat acute attacks of gouty arthritis, but they are reserved primarily for resistant cases or for patients with a contraindication to colchicine and NSAID therapy. Doses of 40 to 80 USP units of adrenocorticotropic hormone gel are given intramuscularly every 6 to 8 hours for 2 to 3 days, and then the doses are reduced in stepwise fashion and discontinued. Intra-articular administration of triamcinolone hexacetonide in a dose of 20 to 40 mg may be useful in treating acute gout limited to one or two joints. Prednisone may be administered orally in doses of 30 to 60 mg for 3 to 5 days in patients with multiple-joint involvement. Because rebound attacks may occur on steroid withdrawal, the dose should be tapered gradually by 5-mg decreases over 10 to 14 days and discontinued. 

---