Background The choice of an optimal anti-inflammatory therapy (AIT) targeting to cut a gouty attack in the shortest terms is based on the assessment of the severity of gouty arthritis (GA), which involves a visual analog scale (VAS) for pain, number of inflamed joints (NIJ) and their sizes, the time since the onset of a gout attack till the beginning of an AIT.
Objectives To determine the influence of comorbidities on the effectiveness of corticosteroids (CS) in patients with GA inadequately responding to previous AIT.
Methods 220 patients with GA were included into the study. The diagnosis was based on GA criteria (ACR, 1977). 88.2% of patients were males. The mean age was 54.5 ± 9.4 years, the mean duration of disease – 8.2 ± 6.8 years. At the beginning, the patients received either NSAIDs or Colchicine with the mean duration of 10.7 ± 5.7. Because of their non-effectiveness, the treatment with CS i.v. or i.m., excepting long-acting CS, was started in clinical setting. The effectiveness of the CS was evaluated after 5 days: 47.3% (n=104) of patients had no signs of inflammation in the joints, and 52.7% (n=116) of them retained the signs of active arthritis. 28 patients continued the same CS, and 88 patients were added a long-acting CS i.m., i.a. or CS per os. Comorbidities included: eGFR <60 ml/min, cardiovascular (CV) pathologies (hypertension (HT), chronic heart failure II-III FC (CHF), ischemic heart disease (IHD), including coronary disease and arrhythmias), diabetes mellitus (DM), elevation of hepatic enzymes, infections.
Results The patients with a little effect of CS as compared to the group of patients with the satisfactory effect had the longer duration of the previous AIT (p<0.001), higher VAS scores (p<0.005), greater NIJ (p<0.000) and the prevalence of polyarthritis (χ2 =15.21; p=0.0001).
Among the patients without a significant effect of CS, as opposed to the patients who responded positively to the CS treatment, more cases of eGFR <60 ml /min. were detected (52.6% and 29.8%; OR - 2.71; 95% CI, 2.11 – 3.48; p=0.0004). In the same group, we noted the prevalence of CV pathologies in general (86.2% and 75%; OR - 2.08; 95% CI, 1.39 – 3.13; p=0.035), in particular, CHF (24.1% and 9.6%; OR =2.99, 95% CI 2.35 - 3.81, p=0.004) and IHD (41.4% and 23.1%; OR =2.02, 95% CI 1.58 - 2.58, p=0.004), but not HT (p>0.05). No statistically significant difference in the number of patients with DM between the groups was found (23.3% and 13.5%; χ2 =3.42; p=0.062). At the same time, elevation of hepatic enzymes by more than 2-fold was observed more frequently in patients with a good effect of CS (χ2 =5.70, p=0.017). The proportions of patients with the presence of infections were distributed quite equally in both groups (7.4% and 6.1%; p>0.05).
Conclusions Refractoriness to anti-inflammatory drugs in patients with gout along with the parameters of GA severity may also be due to comorbid disorders, such as kidney failure and CV disease (CHF, IHD). Therefore, the assessment of the GA severity for the optimal anti-inflammatory approach might include the assessment of these comorbidities. Their presence should be an indication to an early use of either a monotherapy or combinations of CS that would meet the targets of treatment.
Disclosure of Interest None declared