Two review authors independently selected trials for inclusion, assessed the risk of bias and extracted the data. If appropriate, we pooled data in a meta-analysis. We assessed the quality of the evidence using the GRADE approach.
MAIN RESULTS: We included four studies (806 participants) in the review. The studies had an unclear risk of selection bias and low risk of performance and attrition biases. One study each had an unclear risk of detection and selection bias.Three studies (654 participants) compared subcutaneous
canakinumab compared with intramuscular
triamcinolone acetonide 40 mg in the treatment of acute
gout flares of no more than five days' duration. Doses of
canakinumab were varied (10 to 150 mg), but most people (255/368) were treated with
canakinumab 150 mg. None of the studies provided data on participant-reported
pain relief of 30% or greater. Moderate-quality evidence indicated that
canakinumab 150 mg was probably superior to
triamcinolone acetonide 40 mg in terms of
pain relief, resolution of joint swelling and in achieving a good treatment response at 72 hours following treatment, but was probably associated with an increased risk of adverse events.Mean
pain (0- to 100-mm visual analogue scale (VAS), where 0 mm was no
pain) was 36 mm after
triamcinolone acetonide treatment;
pain was further reduced by a mean of 11 mm with
canakinumab treatment (mean difference (MD) -10.6 mm, 95% confidence interval (CI) -15.2 to -5.9). Forty-four per cent of participants treated with
canakinumab had resolution of joint swelling at 72 hours compared with 32% of participants treated with
triamcinolone (risk ratio (RR) 1.39, 95% CI 1.11 to 1.74, number needed to treat for an addition beneficial outcome (NNTB) 9); 65% of participants treated with
canakinumab assessed their response to treatment as good or excellent compare with 47% of participants treated with
triamcinolone acetonide (RR 1.37, 95% CI 1.16 to 1.61, NNTB 6). Function or health-related quality of life were not measured. In both groups, 0.7% of participants withdrew from treatment (RR 1.1, 95% CI 0.2 to 7.2); there was one death and one alteration of laboratory results in each of the treatment groups. Adverse events were more frequent in participants receiving
canakinumab (61%) compared with
triamcinolone acetonide (51%; RR 1.2, 95% CI 1.1 to 1.4, number needed to treat for an addition harmful outcome (NNTH) 10).Low-quality evidence from one study (152 participants with an acute
gout flare of no more than 48 hours' duration and affecting fewer than four joints) comparing
rilonacept 320 mg with
indomethacin (50 mg three times a day for three days followed by 25 mg three times a day for up to nine days) indicated that
indomethacin may improve
pain more than
rilonacept at 24 to 72 hours, and there may be no evidence of a difference in withdrawal rates or adverse events. The mean change (improvement) in
pain from baseline with
indomethacin was 4.3 points (measured on a 0 to 10 numerical rating scale, where 0 was no
pain);
pain was improved by a mean of only 2.5 points with
rilonacept (MD 2.52, 95% CI 0.29 to 4.75, 25% less improvement in absolute
pain with
rilonacept).
Inflammation, function health-related quality of life and participant global assessment of treatment success were not measured. Rates of study withdrawals due to adverse events were low in both groups: 1/75 (1%) participants in the
rilonacept group compared with 2/76 (3%) participants in the
indomethacin group (RR 0.5, 95% CI 0.05 to 5.5). Adverse events were reported in 27/75 (36%) participants in the
rilonacept group and 23/76 (30%) in the
indomethacin group (RR 1.2, 95% CI 0.8 to 1.9).
AUTHORS' CONCLUSIONS: Moderate-quality evidence indicated that compared with a single suboptimal 40-mg dose of
intramuscular injection of
triamcinolone acetonide, a single subcutaneous dose of 150 mg of
canakinumab probably results in better
pain relief, joint swelling and participant-assessed global assessment of treatment response in people with an acute
gout flare but is probably associated with an increased risk of adverse events. The cost of
canakinumab is over 5000 times higher than
triamcinolone acetonide; however, there are no data on the cost-effectiveness of this approach. We found no studies comparing
canakinumab with more commonly used first-line
therapies for acute
gout flares such as
NSAIDs or
colchicine. Low-quality evidence indicated that compared with maximum doses of
indomethacin (50 mg three times a day), 320 mg of
rilonacept may provide less
pain relief with a similar rate of adverse events.