Rationale:

• Each of these medications has different mechanisms of action and potential adverse effects, depending on patient disease profiles.

Evidence:

• Indomethacin has traditionally been the nonsteroidal anti-inflammatory drug (NSAID) used in acute gout, but other NSAIDs are effective. Starting NSAID treatment immediately at anti-inflammatory doses is probably more important than the specific agent used (13; 42); some authors advocate a loading dose of NSAID to hasten onset of action (13; 43).
• Triamcinolone acetonide has been shown to be as effective as indomethacin in the treatment of acute gout attacks (44) and may be useful in patients who cannot take NSAIDs.
• Adrenocorticotropic hormone (ACTH) produced more rapid relief of symptoms and had fewer side effects than oral indomethacin in treatment of acute gout (45).
• A retrospective review found that ACTH is safe and effective treatment for acute gout and pseudogout, especially in patients with multiple comorbid conditions (46).
• A review examined the need for individualized treatment for patients with gouty arthritis (47).
• In a study comparing triamcinolone and ACTH as treatment of acute gouty arthritis, triamcinolone resulted in fewer rebound attacks (48).
• Corticosteroids may be given orally or intramuscularly, or stimulated with ACTH injections; efficacy is similar to that of NSAIDs (44; 48). Injections of ACTH have a short duration of action, requiring multiple daily doses.
• Corticosteroids have been used effectively in lieu of colchicine (49; 50).
• Because of the potential toxicity of colchicine, particularly when it is used intravenously in patients with renal insufficiency, reviews and guidelines for its use have appeared in the literature (51; 52).

Comments:

• None.