Level 1: Likely reliable evidence

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for the treatment of acute gout. The efficacy of NSAIDs compared with prednisolone was evaluated in a randomized trial of 90 patients older than 17 years with a clinical diagnosis of goutlike arthritis (Ann Emerg Med. 2007;49:670-677). Patients were randomized within three days of onset to oral prednisolone vs. NSAIDs.

Prednisolone dosage was 30 mg daily for five days. The NSAIDs group was given diclofenac 75 mg IM, oral indomethacin 50 mg three times daily for two days, then oral indomethacin 25 mg three times daily for three days. All patients were permitted to take acetaminophen 1 g every four hours as needed.

Corresponding placebos were used for all treatments to maintain blinding. Pain scores were measured on a 10-cm scale.

The mean rate of decrease in pain scores at rest was 9.5 mm/hr with prednisolone vs. 6.4 mm/hr with NSAIDs (P = .12), and the mean rate of decrease in pain scores with activity was 19.2 mm/hr vs. 20.3 mm/hr (not significant). NSAIDs were associated with more adverse effects (63% vs. 27%, NNH 2) that reached significance, including epigastric pain (30% vs. 0, NNH 3), dizziness (19% vs. 5%, NNH 7), indigestion (30% vs. 9%, NNH 4), nausea (26% vs. 9%, NNH 5), vomiting (9% vs. 0, NNH 11), and GI hemorrhage (11% vs. 0, NNH 9). NSAIDs were also associated with more serious adverse events requiring hospital admission (15% vs. 0, P = .007, NNH 6).