Letter to the Editor
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
Mariano Andrésa,b, Alejandra Begazoc, Francisca Siverad,b, Paloma Velaa,b, Pedro Zapatere,f, Eliseo Pascuala,g,
Autor para correspondencia
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
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array:7 [ 0 => array:3 [ "entidad" => "Sección de Reumatología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Reumatología, Hospital General Universitario Los Arcos del Mar Menor, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sección de Reumatología, Hospital General Universitario de Elda, Alicante, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sección de Farmacología Clínica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Farmacología, Pediatría y Química Orgánica, Universidad Miguel Hernández, Alicante, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Catedrático emérito de Medicina (Reumatología), Universidad Miguel Hernández, Alicante, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una pequeña dosis de triamcinolona intraarticular más mepivacaína proporciona un alivio rápido y sostenido de los ataques de gota" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1508 "Ancho" => 1887 "Tamanyo" => 44307 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pain assessed by the study participants on a 0–4 Likert semiquantitative scale during the follow-up. <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 for the whole pain reduction throughout the study. P<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 for all the individual comparisons between 15<span class="elsevierStyleHsp" style=""></span>min, 6<span class="elsevierStyleHsp" style=""></span>h, 24<span class="elsevierStyleHsp" style=""></span>h and 72<span class="elsevierStyleHsp" style=""></span>h time-points and baseline.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">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 days<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–4</span></a> 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.</p><p id="par0010" class="elsevierStylePara elsevierViewall">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 (16<span class="elsevierStyleHsp" style=""></span>mg in knees, 8<span class="elsevierStyleHsp" style=""></span>mg in 1st metatarso-phalangeal (1stMTP) joint and 12<span class="elsevierStyleHsp" style=""></span>mg in intermediate sized joints) adding 2<span class="elsevierStyleHsp" style=""></span>ml of 2% mepivacaine in knees, 1–1.5<span class="elsevierStyleHsp" style=""></span>ml in intermediate sized joints, and 0.2–0.4<span class="elsevierStyleHsp" style=""></span>ml in 1stMTP joints, in accordance to our usual clinical practice.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Joint pain was registered using a 0–4 Likert semiquantitative scale (0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>absent; 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>severe) at baseline and 15<span class="elsevierStyleHsp" style=""></span>min, 6<span class="elsevierStyleHsp" style=""></span>h, 24<span class="elsevierStyleHsp" style=""></span>h, and 72<span class="elsevierStyleHsp" style=""></span>h after the injection. Presence of joint swelling and erythema were also collected at baseline and after 72<span class="elsevierStyleHsp" style=""></span>h. Treatment response after 72<span class="elsevierStyleHsp" style=""></span>h was evaluated by both the physician and the patient on a 0–4 Likert scale (0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>no effect; 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>complete resolution). Between-after comparisons were analysed using Friedman and Wilcoxon signed-rank tests.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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 72<span class="elsevierStyleHsp" style=""></span>h, the end of the registrations, as patients reported it (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In only three cases (12.5%), all with 1stMTP attacks, the pain intensity rebounded between 15<span class="elsevierStyleHsp" style=""></span>min and 6<span class="elsevierStyleHsp" style=""></span>h after the injection. Treatment was clearly effective as assessed by both patients and rheumatologists (3 (3–4) and 3.5 (3–4), respectively).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">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 15<span class="elsevierStyleHsp" style=""></span>min after the injection and maintenance of a symptom – free to tolerable pain until subsidence of the symptoms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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 4<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Interestingly, dexamethasone added to mepivacaine in brachial plexus anaesthesia prolonged the time of anaesthesia from a mean of 228<span class="elsevierStyleHsp" style=""></span>min up to 332<span class="elsevierStyleHsp" style=""></span>min, a highly significant change.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> 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.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">This study had no external funding source</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1508 "Ancho" => 1887 "Tamanyo" => 44307 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pain assessed by the study participants on a 0–4 Likert semiquantitative scale during the follow-up. <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 for the whole pain reduction throughout the study. P<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 for all the individual comparisons between 15<span class="elsevierStyleHsp" style=""></span>min, 6<span class="elsevierStyleHsp" style=""></span>h, 24<span class="elsevierStyleHsp" style=""></span>h and 72<span class="elsevierStyleHsp" style=""></span>h time-points and baseline.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.A. 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Qu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/AAP.0b013e3181e85eb9" "Revista" => array:6 [ "tituloSerie" => "Reg Anesth Pain Med" "fecha" => "2010" "volumen" => "35" "paginaInicial" => "422" "paginaFinal" => "426" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20814282" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/1699258X/0000001800000002/v1_202202050622/S1699258X20301145/v1_202202050622/en/main.assets" "Apartado" => array:4 [ "identificador" => "42682" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Carta al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/1699258X/0000001800000002/v1_202202050622/S1699258X20301145/v1_202202050622/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X20301145?idApp=UINPBA00004M" ]
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| 2023 Agosto | 23 | 12 | 35 |
| 2023 Julio | 30 | 18 | 48 |
| 2023 Junio | 31 | 24 | 55 |
| 2023 Mayo | 35 | 19 | 54 |
| 2023 Abril | 23 | 10 | 33 |
| 2023 Marzo | 45 | 25 | 70 |
| 2023 Febrero | 37 | 22 | 59 |
| 2023 Enero | 43 | 28 | 71 |
| 2022 Diciembre | 47 | 37 | 84 |
| 2022 Noviembre | 49 | 25 | 74 |
| 2022 Octubre | 55 | 33 | 88 |
| 2022 Septiembre | 47 | 45 | 92 |
| 2022 Agosto | 31 | 39 | 70 |
| 2022 Julio | 1 | 2 | 3 |
| 2022 Marzo | 2 | 4 | 6 |
| 2022 Febrero | 4 | 0 | 4 |
| 2021 Noviembre | 1 | 0 | 1 |
| 2021 Marzo | 0 | 2 | 2 |
| 2021 Enero | 0 | 2 | 2 |
| 2020 Noviembre | 0 | 2 | 2 |
| 2020 Octubre | 1 | 2 | 3 |
| 2020 Septiembre | 0 | 1 | 1 |
| 2020 Julio | 3 | 4 | 7 |
| 2020 Junio | 3 | 6 | 9 |
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