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either NSAIDs or colchicine (for gouty arthritis) for treating acute flares. 3,4
Those favoring the use of corticosteroids in acute crystal arthropathy contend
that the short-term use of these agents does not incur the well-known problems
occurring with longer-term use. 1 When PO corticosteroids are employed
for crystal arthropathy, recommendation is for daily doses of 40–60 mg prednisone.
4 One trial suggested that the combination of an oral corticosteroid
plus acetaminophen (paracetamol) provides equal pain relief to indomethacin,
and is associated with fewer side effects. 1
Corticosteroids may be given parenterally for patients who cannot tolerate
PO therapy (e.g. those with post-colchicine GI symptoms). As an example, IV
methylprednisolone (100 mg IV) is known to ameliorate acute gout pain. 4
If the ED provider can definitively rule out infectious arthropathy, joint
injection therapy is a therapeutic alternative. Intra-articular administration of
corticosteroids (e.g. methylprednisolone 10–40 mg depending on joint size)
provides some pain relief in crystal arthropathy. 4
Intramuscular corticotropin in two or three doses of 40–80 units given 8–12 h
apart, is a useful option for pain caused by acute gout or pseudogout. 15 The
two-dose regimen is necessary, since single-dose therapy is associated with
higher rates of rebound pain than other approaches (e.g. intra-articular
corticosteroid injection). 4,16 Corticotropin appears to relieve gout pain via a
melanocortin receptor subtype, so its efficacy is unrelated to whether patients
are adrenally insufficient. 17 It is reasonable to use corticotropin as first-line
therapy in patients with acute polyarticular gout, or in those with renal impairment
or other medical diseases (e.g. congestive heart failure, GI bleeding) that
increase the risks from other anti-gout therapies such as NSAIDs. 15,18,19
There is little evidence specifically addressing acute pain relief for other
deposition-related arthropathies (e.g. from hydroxyapatite), but the general
approach of NSAIDs or corticosteroids probably constitutes the best initial
therapy. 20
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For patients with OA in the acute care setting, acetaminophen remains a
reasonable initial analgesic choice in selected patients. This is especially true