AB1028 Acth vs betamethasone for the treatment of acute gout in hospitalisedpatients An open label, comparative study

Background The management of gout can be problematic in the hospital setting; hospitalised patients usually have significant comorbidities and receive multiple medications which leads to a high frequency of contraindications to established gout therapies. We have previously shown the ACTH is a safe and fast acting therapeutic option for acute gout in hospitalised patients in a large scale retrospective study.1 Objectives To directly compare the efficacy of ACTH vs betamethasone for the treatment of acute gout in hospitalised patients in a prospective manner. Methods Hospitalised patients with acute gout, fulfilling the ACR criteria, were treated with an IM injection of either 100 IU of ACTH (Synachten Depot) or 6 mg of betamethasone (Celestone Chronodose-the most widely use IM steroid formulation in our country) on an alternate 1/1 basis. Clinical efficacy was assessed at 24, 48, 72 hour and 5 days as follows: a) Intensity of pain using a Visual Analogue Scale (VAS 0–10), b) physician global assessment (0–10) and c) swelling, redness and warmth (0–3 scale). Pain VAS was also self reported by the patient at 6 and 12 hour. Comorbidities representing contraindications to established gout therapies were recorded. Primary outcome of the study was the change in pain VAS at 24 and 48 hour. Secondary outcomes were changes in physician global assessment and changes in objective signs of inflammation. Results This is a 6 month interim analysis of an ongoing investigator initiated clinical study. Twelve patients (8 male) with a mean ±SD of 66.9±12.3 years were recruited and treated with ACTH or betamethasone on an alternate basis (6 in each treatment group). In most cases (n=11) the attack was monoarticular. The majority of patients had multiple comorbidities with the commonest being hypertension (9/12). Both treatments were effective. ACTH led to a significant decline in pain VAS at 24 hour compared to baseline (mean ±SEM: 2.33±1.21 vs 7.66±0.81 respectively, p=0.0002) and at 48 hour (1.40±1.14, p=0.0011 compared to baseline). Betamethasone was also effective with an improvement in pain VAS at 24 hour compared to baseline (mean ±SEM: 1.83±0.98 vs 5.33±2.16 respectively, p=0.0024) and at 48 hour (0.75±0.95, p=0.02 compared to baseline). However, direct comparison between treatment arms showed that ACTH treated patients exhibited a higher change in pain VAS at 24 hour compared to betamethasone treated patients (mean ±SEM: 5.5±0.5 vs 3.5±0.61 respectively, p=0.03). At the 48 hour time point ACTH treated patients still showed a higher change in pain VAS (mean ±SEM: 6.4±0.6 vs 4±0.91 respectively, p=0.056). A trend favouring ACTH was already evident at the 12 hour time point; the change in pain VAS was 4±1.54 vs 3.1±1.47 for ACTH vs betamethasone, respectively, p=ns). No changes in physician global assessment and objective signs of inflammation was found at 24 and 48 hour between treatment groups. Treatment was well tolerated in both groups. Conclusions Both steroids and ACTH are effective in the treatment of gout in hospitalised patients but ACTH is faster acting. ACTH may be an attractive therapeutic choice in patients with multiple comorbidities that cannot receive standard treatment. References [1] Daoussiset al, Joint Bone Spine, 2013 Disclosure of Interest P. Kordas: None declared, I. Antonopoulos: None declared, D. Velissaris: None declared, D. Daoussis Speakers bureau: Mallinckrodt Pharmaceuticals