Abstract
The aim of this study was to systematically review the literature on effect of initiating urate-lowering treatment (ULT) during an acute attack of gout on duration of index attack and persistence on ULT. OVID (Medline), EMBASE and AMED were searched to identify randomized controlled trials (RCTs) of ULT initiation during acute gout attack published in English language. Two reviewers appraised the study quality and extracted data independently. Standardized mean difference (SMD) and relative risk (RR) were used to pool continuous and categorical data. Meta-analysis was carried out using STATA version 14. A total of 537 studies were selected. A total of 487 titles and abstracts were reviewed after removing duplicates. Three RCTs were identified. There was evidence from two high-quality studies that early initiation of allopurinol did not increase pain severity at days 10–15 [SMDpooled (95 % CI) 0.18 (−0.58, 0.93)]. Data from three studies suggested that initiation of ULT during an acute attack of gout did not associate with dropouts [RRpooled (95 % CI) 1.16 (0.58, 2.31)]. There is moderate-quality evidence that the initiation of ULT during an acute attack of gout does not increase pain severity and risk of ULT discontinuation. Larger studies are required to confirm these findings so that patients with acute gout can be initiated on ULT with confidence.Electronic supplementary materialThe online version of this article (doi:10.1007/s00296-016-3579-z) contains supplementary material, which is available to authorized users.
Highlights
Gout is the commonest inflammatory arthritis and results from monosodium urate (MSU) crystal deposition
While the British Society for Rheumatology (BSR) and European League Against Rheumatism (EULAR) guidelines suggest commencing urate-lowering treatment (ULT) 1–2 weeks after the acute attack has resolved, the 2012 American College of Rheumatology (ACR) guidelines suggest that ULT may be started during an acute attack [1,2,3]
Data from only the first 28 days from one of the studies could be included [5] as that study compared the effect of azapropazone or regular indomethacin followed by delayed initiation of allopurinol on day 28, on treatment of the acute attack of gout and in preventing recurrent gout attacks [5]
Summary
Gout is the commonest inflammatory arthritis and results from monosodium urate (MSU) crystal deposition. While the British Society for Rheumatology (BSR) and European League Against Rheumatism (EULAR) guidelines suggest commencing ULT 1–2 weeks after the acute attack has resolved, the 2012 American College of Rheumatology (ACR) guidelines suggest that ULT may be started during an acute attack [1,2,3]. These recommendations are discordant, and the latest Cochrane review did not examine the effect of ULT initiation during an acute attack of gout on its duration and severity [4]. Further research is required to examine whether ULT can be initiated during an acute gout attack, without unduly prolonging the index episode
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