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Colchicine for acute gout

 

Clinical bottom line

The one randomised trial found for colchicine in gout concluded that severe diarrhoea occurred before relief of pain or clinical response in most patients.


Bandolier set out to perform a systematic review of randomised, double-blind, placebo- or active-controlled studies of colchicine for the treatment of acute gout. Using PubMed and the Cochrane Library, we found only a single trial.

Reference


MJ Ahern et al. Does colchicine work? The results of the first controlled study in acute gout. Aust NZ J Med 1987 17: 301-304.


Study

The study was a randomised comparison colchicine and placebo in patients with acute gout confirmed by joint aspiriation and demonstration of negatively birefringent needle shaped crystals. Randomisation method was not stated, but the placebo and treatment were matched, and withdrawal not mentioned specifically except in relation to toxicity with colchicine. The trial would score 3 or 4 out of 5 using a standard scale of trial quality.

The initial dose of colchicine was 1 mg orally, followed by another 0.5 mg every two hours until complete response or toxicity. No NSAID was allowed for 48 hours before or during the study.

Every six hours until 48 hours from initial dose patients were evaluated for pain, tenderness, redness and swelling (on a four point, 0-3 score, so maximum was 12). Pain as measured with a visual analogue scale ((details not given).

Results

Colchicine (N=22) and placebo groups (N=21) were the same at baseline. The mean age was 70 years, each patient has a single joint involved, the mean serum creatinine was 0.5 mmol/L, mean duration of symptoms was 38 hours, and mean pain score at baseline was about 60 (apparently out of 100).

Pain

The proportion of patients with at least 50% improvement in their pain score using a visual analogue scale is shown over the first 48 hours in Figure 1. The number needed to treat for 50% improvement in pain is of limited value with these small numbers, but is about 3 at 24 hours and about 3 at 48 hours. The mean pain score was about 50 mm with placebo at 48 hours, and about 15 with colchicine.

Figure 1: At least 50% improvement in VAS pain with colchicine and placebo



Clinical score

The proportion of patients with at least 50% improvement in clinical score is shown over the first 48 hours in Figure 2. The number needed to treat for 50% improvement in clinical score is of limited value with these small numbers, but is about 5 at 24 hours and about 2.5 at 48 hours. The mean clinical score was about 8/12 with placebo at 48 hours, and about 5/12 with colchicine.

Figure 2: At least 50% improvement in clinical score with colchicine and placebo


Toxicity

Diarrhoea and/or vomiting occurred in all patients taking colchicine at a median time of 24 hours after a mean dose of 6.7 mg. Occurrence of half pain relief occurred before toxicity in nine patients, after toxicity in 12 and concurrently in one. For 20 patients out of 22, toxicity occurred before a 50% improvement in clinical score.

Some nausea was noted in five patients taking placebo

Comment

Toxicity preceded effect in most patients.

It is sobering that the sum total of randomised patients that could be found for the evidence on use of colchicine in acute gout was 43.

Bandolier could have performed an inefficient search, but an independent search gave no different answer, and repeating the search in different ways produced no more. As always, if you know of a trial we have missed, please email. If pharmaceutical companies have information, we'd like to know about that as well.