MAJ 2016(cf infra)
Un essai randomisé a comparé la prednisolone orale (30 mg d’emblée, puis 1 fois/jour pendant 5 jours) à l’indométacine (50 mg d’emblée, puis 50 mg x 3/jour pendant 2 jours, puis 25 mg x 3/jour pendant 3 jours) chez 416 adultes présentant une crise de goutte. L’effet antalgique mesuré sur une échelle visuelle analogique (EVA) de 100 mm a été comparable, tant au cours des premières heures qu’ensuite, et tant au repos que pendant les activités. Les effets indésirables mineurs ont été plus fréquents sous indométacine au cours de la phase initiale.
L’efficacité de la prednisolone (Solupred*) à la dose de 35 mg une fois par jour pendant 5 jours est identique à celle d’un AINS, le naproxène (Naprosyne*), 500 mg deux fois par jour pendant 5 jours.
le paracétamol est le médicament de référence éventuellement associé à un AINS. L’ibuprofène (200 à 400 mg/j) est à privilégier car il provoque moins d’effets indésirables digestifs [Lire]
Les corticoïdes ne sont pas évalués dans cet avis
Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial
Dr Hein JEM Janssens MD a , Matthijs Janssen PhD c, Eloy H van de Lisdonk PhD a, Prof Piet LCM van Riel PhD b and Prof Chris van Weel PhD
Non-steroidal anti-inflammatory drugs and colchicine used to treat gout arthritis have gastrointestinal, renal, and cardiovascular adverse effects. Systemic corticosteroids might be a beneficial alternative. We investigated equivalence of naproxen and prednisolone in primary care.
We did a randomised clinical trial to test equivalence of prednisolone and naproxen for the treatment of monoarticular gout. Primary-care patients with gout confirmed by presence of monosodium urate crystals were eligible. 120 patients were randomly assigned with computer-generated randomisation to receive either prednisolone (35 mg once a day; n=60) or naproxen (500 mg twice a day; n=60), for 5 days. Treatment was masked for both patients and physicians. The primary outcome was pain measured on a 100 mm visual analogue scale and the a priori margin for equivalence set at 10%. Analyses were done per protocol and by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN14648181.
Data were incomplete for one patient in each treatment group, so per-protocol analyses included 59 patients in each group. After 90 h the reduction in the pain score was 44·7 mm and 46·0 mm for prednisolone and naproxen, respectively (difference 1·3 mm; 95% CI -9·8 to 7·1), suggesting equivalence. The difference in the size of change in pain was 1·57 mm (95% CI -8·65 to 11·78). Adverse effects were similar between groups, minor, and resolved by 3 week follow-up.
Oral prednisolone and naproxen are equally effective in the initial treatment of gout arthritis over 4 days.
Funding Rheumatology Research Fund Arnhem, Netherlands.
Source: [Ann Intern Med. 2016;164(7):464-471]
Timothy Hudson Rainer, MD*; Chi Hung Cheng, MD*; Hein J.E.M. Janssens, MD, PhD; Chi Yin Man, MD; Lai Shan Tam, MD; Yu Fai Choi, MD; Wah Hon Yau, MD; Ka Hing Lee, MD; and Colin Alexander Graham, MD [+] Article, Author, and Disclosure Information Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070 © 2016 American College of Physicians Text Size: A A A This article was published at www.annals.org on 23 February 2016. * Professor Rainer and Dr. Cheng contributed equally to this work.
Background: Two recent double-blind, randomized, controlled trials (RCTs) showed that oral steroids and nonsteroidal anti-inflammatory drugs have similar analgesic effectiveness for management of gout, but the trials had small sample sizes and other methodological limitations.
Objective:To compare the effectiveness and safety of oral prednisolone versus oral indomethacin in patients presenting to emergency departments (EDs) with acute gout.
Design: Multicenter, double-blind, randomized equivalence trial. Patients were randomly assigned (1:1 ratio) to receive either indomethacin or prednisolone. (ISRCTN registry number: ISRCTN45724113)
Setting: Four EDs in Hong Kong.
Participants: 416 patients aged 18 years or older.
Measurements: Analgesic effectiveness was defined as changes in pain (at rest or with activity) greater than 13 mm on a 100-mm visual analogue scale. Outcomes were measured during the first 2 hours in the ED and from days 1 to 14.
Results: 376 patients completed the study. Equivalent and clinically significant within-group reductions in mean pain score were observed with indomethacin and prednisolone in the ED (approximately 10 mm [rest] and 20 mm [activity]) and from days 1 to 14 (approximately 25 mm [rest] and 45 mm [activity]). No major adverse events occurred during the study. During the ED phase, patients in the indomethacin group had more minor adverse events than those in the prednisolone group (19% vs. 6%; P < 0.001). During days 1 to 14, 37% of patients in each group had minor adverse events.
Limitation: Diagnosis of gout was usually based on clinical criteria rather than examination of joint fluid.
Conclusion: Oral prednisolone and indomethacin had similar analgesic effectiveness among patients with acute gout. Prednisolone is a safe, effective first-line option for treatment of acute gout.
Primary Funding Source: Health and Health Services Research Grant Committee of the Hong Kong Government.