Publique en esta revista
Información de la revista
Vol. 18. Núm. 2.
Páginas 129-130 (Febrero 2022)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 18. Núm. 2.
Páginas 129-130 (Febrero 2022)
Letter to the Editor
Acceso a texto completo
A small dose of intraarticular triamcinolone plus mepivacaine provides a rapid and sustained relief for gout flares
Una pequeña dosis de triamcinolona intraarticular más mepivacaína proporciona un alivio rápido y sostenido de los ataques de gota
Visitas
...
Mariano Andrésa,b, Alejandra Begazoc, Francisca Siverad,b, Paloma Velaa,b, Pedro Zapatere,f, Eliseo Pascuala,g,
Autor para correspondencia
pascual_eli@gva.es

Corresponding author.
a Sección de Reumatología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
b Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
c Sección de Reumatología, Hospital General Universitario Los Arcos del Mar Menor, Murcia, Spain
d Sección de Reumatología, Hospital General Universitario de Elda, Alicante, Spain
e Sección de Farmacología Clínica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
f Departamento de Farmacología, Pediatría y Química Orgánica, Universidad Miguel Hernández, Alicante, Spain
g Catedrático emérito de Medicina (Reumatología), Universidad Miguel Hernández, Alicante, Spain
Información del artículo
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Figuras (1)
Texto completo
Dear Editor:

Most patients describe gout attacks as especially painful. Effective treatments – colchicine, NSAIDs, systemic or intra-articular corticosteroids, interleukin-1 blockers – result in an effective resolution of the attacks; however, it usually requires 1–3 days1–4 to relieve the symptoms, and at least a few hours to start lessening them. After an initial observation, intra-articular triamcinolone with added 2% mepivacaine has become a usual procedure in our clinics, as we have repeatedly observed a very rapid and persistent subsidence of pain. Here we aimed to prospectively document this outcome.

Consecutive patients with crystal-proven gout, suffering from an acute, monoarticular and still untreated flare were recruited. All cases were treated with an intra-articular injection of triamcinolone acetonide (16mg in knees, 8mg in 1st metatarso-phalangeal (1stMTP) joint and 12mg in intermediate sized joints) adding 2ml of 2% mepivacaine in knees, 1–1.5ml in intermediate sized joints, and 0.2–0.4ml in 1stMTP joints, in accordance to our usual clinical practice.5 Joint pain was registered using a 0–4 Likert semiquantitative scale (0=absent; 4=severe) at baseline and 15min, 6h, 24h, and 72h after the injection. Presence of joint swelling and erythema were also collected at baseline and after 72h. Treatment response after 72h was evaluated by both the physician and the patient on a 0–4 Likert scale (0=no effect; 4=complete resolution). Between-after comparisons were analysed using Friedman and Wilcoxon signed-rank tests.

Twenty-four patients were recruited; median (±SD) aged 64.8 years (±12.7), 22 males. Involved joints were sixteen 1stMTPs, five knees, two wrists, and one ankle. Median (p25–75) pain score at baseline was 3 (2.0–3.8), joint swelling was present in all cases, and in 13 cases (54.2%) erythema was observed. After a few minutes of the intra-articular injection, a rapid pain reduction was observed and maintained up to 72h, the end of the registrations, as patients reported it (Fig. 1). In only three cases (12.5%), all with 1stMTP attacks, the pain intensity rebounded between 15min and 6h after the injection. Treatment was clearly effective as assessed by both patients and rheumatologists (3 (3–4) and 3.5 (3–4), respectively).

Fig. 1.

Pain assessed by the study participants on a 0–4 Likert semiquantitative scale during the follow-up. P<0.001 for the whole pain reduction throughout the study. P<0.001 for all the individual comparisons between 15min, 6h, 24h and 72h time-points and baseline.

(0,04MB).

This small study supports our observation from clinical practice: adding mepivacaine to a low dose of intra-articular triamcinolone acetonide leads to an almost immediate relief of gout attacks, with a clear response even 15min after the injection and maintenance of a symptom – free to tolerable pain until subsidence of the symptoms.

The almost immediate pain relief can be attributed to mepivacaine. There are few data on the duration of anaesthesia with this agent, but when used for brachial plexus blockade, it lasts between 3 and 4h.6 Interestingly, dexamethasone added to mepivacaine in brachial plexus anaesthesia prolonged the time of anaesthesia from a mean of 228min up to 332min, a highly significant change.7 A similar effect may occur when triamcinolone and mepivacaine are conjointly injected in a joint affected by a gout flare. An early effect of triamcinolone on the synovial irrigation could reduce the local inflammation-related blood flow, retarding mepivacaine clearance from the joint. The pain reappeared in a number of patients after its initial marked reduction, but with a moderate intensity, likely indicating that by that time, the steroid action has already begin; afterwards the flare totally subsided, although the total time to subsidence in some patients maybe as long as it would be if only steroids would have been injected. These results were highly welcomed both by physicians and especially by patients.

Funding

This study had no external funding source

Conflict of interest

MA has received speaking and advisory fees from Menarini, Grünenthal and Horizon. FS has received speaking and advisory fees from Menarini, Grünenthal and Horizon. The rest of authors declare no conflicts of interest in relation to this work.

References
[1]
R.A. Terkeltaub, D.E. Furst, K. Bennett, K.A. Kook, R.S. Crockett, M.W. Davis.
High versus low dosing of oral colchicine for early acute gout flare: twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study.
Arthritis Rheum, 62 (2010), pp. 1060-1068
[2]
B.R. Rubin, R. Burton, S. Navarra, J. Antigua, J. Londoño, K.G. Pryhuber, et al.
Efficacy and safety profile of treatment with etoricoxib 120mg once daily compared with indomethacin 50mg three times daily in acute gout: a randomized controlled trial.
Arthritis Rheum, 50 (2004), pp. 598-606
[3]
C.M. van Durme, M.D. Wechalekar, R. Buchbinder, N. Schlesinger, D. van der Heijde, R.B. Landewé.
Non-steroidal anti-inflammatory drugs for acute gout.
Cochrane Database Syst Rev, (2014),
[4]
N. Schlesinger, R.E. Alten, T. Bardin, H.R. Schumacher, M. Bloch, A. Gimona, et al.
Canakinumab for acute gouty arthritis in patients with limited treatment options: results from two randomised, multicentre, active-controlled, double-blind trials and their initial extensions.
Ann Rheum Dis, 71 (2012), pp. 1839-1848
[5]
C. Fernández, R. Noguera, J.A. González, E. Pascual.
Treatment of acute attacks of gout with a small dose of intra-articular triamcinolone acetonide.
J Rheumatol, 26 (1999), pp. 2285-2286
[6]
B.G. Covino.
Pharmacology of local anaesthetic agents.
Br J Anaesth, 58 (1986), pp. 701-716
[7]
S.J. Parrington, D. O’Donnell, V.W. Chan, D. Brown-Shreves, R. Subramanyam, M. Qu, et al.
Dexamethasone added to mepivacaine prolongs the duration of analgesia after supraclavicular brachial plexus blockade.
Reg Anesth Pain Med, 35 (2010), pp. 422-426
Copyright © 2020. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Idiomas
Reumatología Clínica

Suscríbase a la newsletter

Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?