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Gout is characterised by hyperuricaemia which is most commonly
caused by either insufficient secretion of uric acid or by overproduction,
and sometimes by both.
Most-affected joints include; lower limb
joints, particularly the big toe, followed
by the midtarsal, ankle, knee and
upper limb joints. The natural history of
articular gout is generally characterised
by three main stages: asymptomatic
hyperuricaemia, episodes of acute gout
and chronic gouty arthritis.2
Non-steroidal anti-inflammatory (NSAID)
medications are usually recommended
for the management of acute gout.
However, their use may be limited by
some of their adverse events especially
in people with cardiovascular diseases,
renal impairment and a history of peptic
ulcer or gastrointestinal bleeding.
This evidence summary is based on a
systematic review that evaluated the
benefit and safety of NSAIDs to treat
acute gout especially with respect to
differences between non-selective
NSAIDs and cyclo-oxygenase Cox
inhibitors, interleukin inhibitors and
The studies included in the
above mentioned review were
randomised controlled trials (RCTs) or
quasi-randomised controlled clinical
trials (CCTs) that compared NSAIDs with
another therapy (active or placebo,
including non-pharmacological therapies)
for the management of acute gout.
Quality of the research
Studies included in the report were
of low to moderate methodological
quality. Biases such potential selection
and reporting biases, and imprecision
were the major drawbacks.
• The following databases were
searched; Cochrane Central Register
of Controlled Trials (CENTRAL),
MEDLINE and EMBASE for studies
ACR and EULAR abstracts, the World
Health Organization (WHO) trial
register, ClinicalTrials.gov, and a hand
search of reference lists of articles.
• The review included 23 trials with a
total of 2,200 participants.
• The main outcome measures
included; Pain improvement by more
than 50% after 24 hours, swelling
improvement by more than 50% after
24 hours and adverse events.
• A total of four studies included the
primary benefit endpoint of proportion
of participants improved by 50% or
more and 18 studies included the
primary safety endpoint of withdrawals
due to adverse events. Some studies
could not be pooled together due
to their high risk of bias and use of
different outcome measures.
• One study of 30 participants
compared tenoxicam 40 mg with
placebo and found no between
group differences with respect to the
number of participants who achieved
a more than 50% reduction in pain
with movement at 24 hours.
• Four studies comparing NSAIDs with
placebo reported on a non-significant
pain reduction for a mean follow up of
• One study of 30 participant comparing
NSAIDs with placebo reported a non-
significant reduction in inflammation,
RR=1.08 (95%CI 0.79-1.99).
The e cacy of NSAIDs in the
treatment of acute gout
BY DR HANAN KHALIL
Dr Hanan Khalil is the Director of the Centre for
Chronic Disease Management, a collaborating centre
of the Joanna Briggs Institute, Faculty of Medicine,
Nursing and Health Sciences, Monash University, and
a reviewer for the consumer group of the Cochrane
Collaboration. Hanan is also the Editor in Chief of the
International Journal of Evidenced Based Health Care.
The purpose of this evidence summary is to provide
the best available evidence for the efficacy of
non-steroidal anti-inflammatory medications in
the management of acute gout. For the full review,
please refer to: van Durme CMPG, Wechalekar MD,
Buchbinder R, Schlesinger N, van der Heijde D,
Landewé RBM. Non-steroidal anti-inflammatory drugs
for acute gout. Cochrane Database of Systematic
• One high risk bias study with 225
participants found that NSAIDs
provided greater pain relief than
• No studies reported on joint function,
global assessment of treatment, health
related quality of life and withdrawals
due to adverse events.
Implications for research and
From the results shown above, it was
difficult to determine whether NSAIDs
are more superior than other medications
such as COX 2 inhibitors, gluco-corticoids
and interleukin inhibitors in the
management of acute gout. Further
studies with more robust methodologies
are needed to confirm these findings.
The current evidence supports the
recommendations based in the current
guidelines regarding the use of NSAIDs
in the management of acute gout.
NSAIDs may have a role in short term
relief of acute gout symptoms but not for
1. van Durme CMPG, Wechalekar MD, Buchbinder R,
Schlesinger N, van der Heijde D, Landewé RBM. Non-
steroidal anti-inflammatory drugs for acute gout. Cochrane
Database of Systematic Reviews 2014, Issue 9. Art. No.:
CD010120. [DOI: 10.1002/14651858.CD010120.pub2]
2. Marks JL, Colebach AN, Buchbinder R, Edwards CJ. Pain
management for rheumatoid arthritis and cardiovascular
or renal comorbidity. Cochrane Database of Systematic
Reviews 2011, Issue 10. [DOI: 10.1002/ 14651858.CD008952.
3. Jordan KM, Cameron JS, Snaith M, Zhang W, Doherty M,
Seckl J, et al. British Society for Rheumatology and British
Health Professionals in Rheumatology guideline for the
management of gout. Rheumatology 2007;46(8):1372--4.
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