The Pharmaceutical Journal
Vol 272 No 7299 p598
15 May 2004

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Woeful lack of evidence for gout treatments, says DTB

There is a “woeful” lack of evidence to guide treatment or prophylaxis for gout, particularly with regard to choice of drug or doses, according to the latest issue of Drug and Therapeutics Bulletin. Its editor Joe Collier said: “It is astonishing that we know so little about how best to treat the common (and very painful) condition gout. The drugs used are old, so there is no drive to do the necessary research. This is an unacceptable position and needs remedying.”

The DTB advises that non-steroidal anti-inflammatory agents are a standard first-line treatment for acute gout. But it adds that there are few randomised controlled trials to guide the choice of agent. “What evidence there is suggests there is no difference in efficacy or tolerability between any of the NSAIDs.” Although colchicine is an alternative drug for patients who cannot take an NSAID, its side effects of diarrhoea and vomiting are common. A reduced dose of 500µg up to three times daily may avoid these effects. Paracetamol or an opiate such as codeine are effective and could be used alone or in combination with an NSAID or other treatments.

“Deciding when to start lifelong prophylactic therapy presents another problem in the management of gout,” again with a lack of guiding evidence, says the bulletin. Although some clinicians advise that patients who have two or more attacks per year should be offered prophylactic therapy, in practice the decision is often left to the patient.

The DTB adds that, although allopurinol and sulfinpyrazone lower serum uric acid concentrations, it can find no published randomised controlled studies showing a reduction in the likelihood of having attacks of gout.

There are also no published controlled trials which examine the effect of lifestyle changes on the frequency of gout. However, the bulletin says there is some evidence that modifying body weight and diet can influence serum uric acid concentrations and possibly help prevent attacks (2004;42:37).