Background Patients with gout have multiple comorbidities that often preclude the use of currently recommended drugs. Evidence suggests that adrenocorticotropic hormone (ACTH) is effective, fast acting and exhibits an excellent safety profile.
Objectives To assess the efficacy and safety of ACTH for the treatment of gout in hospitalized patients.
Methods We retrospectively reviewed our inpatient consultation records and identified 181 cases of gout where ACTH was used as first line treatment. The hospital medical records of these patients were fully reviewed. Comorbidities recorded were: a) hypertension, b) cardiovascular disease, c) chronic kidney disease defined as an estimated glomerular filtration rate of <90ml/min/1.73m2 and d) diabetes mellitus. Patients were treated with 1 mg of ACTH intramuscularly. Complete response to treatment was defined as i) more than 50% improvement in patient’s assessment of pain and physician’s global assessment and ii)attenuation of signs of inflammation and iii) no use of steroids, NDAIDs, colchicine or analgesics for 2 days following the attack. Patients fulfilling 1 or 2 of the above criteria were considered partial responders and patients not fulfilling any criterion were considered non-responders.
Results The most frequent comorbidity was hypertension (80.66%) followed by CVD (54.69%). The vast majority of patients (79.55%) had some degree of renal impairment as indicated by an eGFR <90ml/min/1.73m2. Most patients had hyperuricemia (90.6%) and had experienced at least one gouty attack in the past (83.97%). A complete response was seen in 77.9% of patients, partial response in 19.33% and no response in only 2.76%. Response was evident the day following ACTH injection in all responders with most patients reporting relief of pain within 4-6 hours. Partial responders were retreated with ACTH the day following the first injection; the vast majority of these patients (82.85%) had a complete response. A relatively small percentage of complete responders suffered a second gouty attack (11.34%) at a median of 4 days from the initial attack. They were retreated with ACTH and all had a complete response. Only very few adverse events could be certainly related to ACTH. These included 4 cases of local, mild skin reactions and 1 case of flushing. Two cases of edema, 1 episode of tachycardia/palpitations, 1 episode of headache and 1 episode of dizziness were considered as likely related to ACTH, since they occurred shortly after the injection. Diabetic patients (n=42) who received ACTH treatment showed an increase in fasting glucose levels 24 hours following the injection compared to baseline but this increase was not evident at 48 hours. No significant changes in blood pressure or potassium levels, following ACTH administration were recorded.
Conclusions ACTH is fast acting, highly effective and safe for the treatment of gout in hospitalized patients. ACTH is potentially the most attractive therapeutic option for hospitalized patients since the use of NSAIDs, steroids or colchicine in this patient population may be problematic.
Disclosure of Interest None Declared