#255 Hotcakes: Colchicine for CAD, and Gout flares, PT versus Steroids for Knee OA

February 8, 2021 | By Matthew Watto, MD

Fresh hotcakes! Practice changing articles that you need to know: low dose colchicine for stable CAD; colchicine vs naproxen for acute gout flares; and physical therapy vs glucocorticoid injection for chronic Knee osteoarthritis. We’re joined by Michael Sternberg (Chief resident, VCU Internal Medicine Residency) and our fearless leader of critical appraisal, internist/epidemiologist, Rahul Ganatra MD, MPH, @rbganatra (VA Boston). 

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Credits

• Written and Produced by: Matthew Watto MD, FACP
• Cover Art: Matthew Watto MD, FACP
• Hosts: Rahul Ganatra MD, MPH; Michael Sternberg MD; Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Sponsor: ACP’s MKSAP18

MKSAP® is the most trusted resource for lifelong learning and Board prep for internal medicine physicians and residents. Learn more at www.acponline.org/curb2021.

Sponsor: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

Time Stamps

• Intro, disclaimer
• 01:45 Fun animal fact; Picks of the Week*
• 06:33 PT vs steroid injection for chronic knee OA
• 21:00 Colchicine for stable CAD
• 33:00 Low dose colchicine vs naproxen for acute gout flares

PT vs Steroid Injection for Chronic Knee OA

Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen EJ, Dusenberry DI, Rhon DI. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med. 2020 Apr 9;382(15):1420-1429. doi: 10.1056/NEJMoa1905877. PMID: 32268027.

https://pubmed.ncbi.nlm.nih.gov/32268027/

Question: Does physical therapy improve pain, function and stiffness scores amongst adult patients with chronic knee osteoarthritis (OA) at 1 year follow up?

Comparison: Randomized, unblinded trial of 156 adults (>38 years old) with clinical and radiographic evidence of knee OA were recruited from two US military hospitals (including one third from a PT clinic) and assigned to either PT (up to 8 sessions over 4-6 weeks plus additional sessions at 4 mo and 9 mo) or glucocorticoid injection(s) (triamcinolone 40 mg plus 7mL 1% lidocaine; up to 3 injections in 12 mo period). Patients were excluded if they lacked radiographic OA or had PT or injection within 12 months prior to study entry.

Results: This was a positive trial. Patients had a baseline WOMAC score (assesses pain, stiffness, and function) of 108. At one year, the physical therapy group had lower WOMAC scores compared to GC injection 37+/-30.7 vs 55+/-53.8 with a mean difference between groups of 18.8; 95% CI 5-32.6. Note: A minimum  clinically important difference on the WOMAC is typically 12-16%, which would be an approx. 13-17 point drop from baseline of 108.

Bottom Line: Physical therapy (both passive hands on (“manual therapy”) and active exercise) lead to greater improvements in the WOMAC score at 1 year compared to glucocorticoid injections.

Hotcakes rating:  4.5

Additional reading:

• 2019 ACR Guidelines for OA https://pubmed.ncbi.nlm.nih.gov/31908149/ 

Colchicine for stable CAD

Nidorf SM, Fiolet ATL, Mosterd A, Eikelboom JW, Schut A, Opstal TSJ, The SHK, Xu XF, Ireland MA, Lenderink T, Latchem D, Hoogslag P, Jerzewski A, Nierop P, Whelan A, Hendriks R, Swart H, Schaap J, Kuijper AFM, van Hessen MWJ, Saklani P, Tan I, Thompson AG, Morton A, Judkins C, Bax WA, Dirksen M, Alings M, Hankey GJ, Budgeon CA, Tijssen JGP, Cornel JH, Thompson PL; LoDoCo2 Trial Investigators. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med. 2020 Nov 5;383(19):1838-1847. doi: 10.1056/NEJMoa2021372. Epub 2020 Aug 31. PMID: 32865380.

https://pubmed.ncbi.nlm.nih.gov/32865380/

Question: Does low dose colchicine (LoDoCo) prevent major adverse cardiac events (MACE) in patients with chronic stable coronary artery disease (CAD) after median follow up of 28.6 months?

Comparison: 5522 adult patients ages 35-82 years old with stable CAD (from Australia or The Netherlands) were randomized to LoDoCo (n=2762) vs placebo (2760) after a 1 month run-in to ensure tolerance of LoDoCo. The trial excluded patients with moderate to severe CKD (stage 3b or 4/5), severe CHF or valvular disease or known intolerance to colchicine.

Results: This was a positive trial. Fewer patients taking LoDoCo experienced the primary outcome (composite of CV death, MI, stroke or “ischemia driven revascularization”) 187 patients (6.8%) vs 264 patients (9.6%) in the placebo group (incidence of 2.5 vs 3.6 events per 100 person-years; HR 0.69; 95% CI 0.57-0.83; p<0.001). Unexpectedly, the incidence of death from noncardiovascular causes was higher in the LoDoCo group than the placebo group (0.7 vs 0.5 events per 100 person-years; HR 1.51; 95% CI 0.99 to 2.31).

Bottom Line: Patients with stable CAD who were able to tolerate LoDoCo had significantly less MACE at median follow-up 28.6 months. Notably, no significant myopathic issues were observed with concomitant use of LoDoCo and high dose statins, but these patients had relatively strong renal function. It’s unclear why noncardiovascular death was higher in the LoDoCo group, but this requires further investigation before widespread implementation.

Hotcakes rating: 3.5

Additional reading:

• JWatch Coverage Colchicine after Acute MI
• Colchicine after acute coronary syndrome https://pubmed.ncbi.nlm.nih.gov/32862667/ 

Colchicine vs Naproxen for Acute Gout Flares

Roddy E, Clarkson K, Blagojevic-Bucknall M, et al. Open-label randomised pragmatic trial (CONTACT) comparing naproxen and low-dose colchicine for the treatment of gout flares in primary care. Ann Rheum Dis. 2020;79(2):276-284. doi:10.1136/annrheumdis-2019-216154 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025732/ 

Question: How effective and tolerable is low-dose colchicine (0.5 mg tid for 4 days) compared to naproxen (750 mg loading dose, then 250 mg tid for 7 days) for improving pain during an acute gout flare at 7 days?

Comparison: Randomized, multicenter (100 locations in the UK), open-label trial of 399 adults ≥18 years old presenting to their general practitioner (GP) with a clinical diagnosis of recurrent or initial gout flare and treated with naproxen (n=200) or colchicine (n=199). Patients were excluded if they had CKD 4-5, known GI bleed or ulcers, required anticoagulation, or had known allergy/intolerance to study drug(s). 

Results: Both drugs achieved a significant reduction in pain without a significant difference between the treatment groups at 7 days or 4 weeks. Patients in the colchicine group had higher incidence of diarrhea (NNH 4) and headache (NNH 12) and those in the naproxen group had more constipation (NNH 7). 

Bottom Line: Both low dose colchicine tid for 4 days and naproxen tid for 7 days are effective and safe in an acute gout flare, but naproxen is cheaper, over-the-counter, and has less GI side effects.

Hotcakes rating:  3.5

Additional reading:

• JWatch Coverage Colchicine and New Gout Guidelines 
• 2020 ACR Gout Guidelines with our friend Dr. Tuhina Neogi et al! 
• Colchicine overdose/toxicity (LiverTox site) 

Links*

1. COVID-19 Sniffing Dogs at Miami Heat games (AP News, Tim Reynolds Jan 24, 2021)
2. Ms Grit – Imposter EP – on Spotify
3. Peaky Blinders (TV show)

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goals

Listeners will review recent practice changing articles on colchicine for gout flares, stable CAD; and physical therapy versus steroid injections for knee osteoarthritis

Learning objectives

After listening to this episode listeners will…

1. Discuss the efficacy of colchicine for prevention of major adverse cardiac events in stable coronary disease
2. Discuss practical considerations and efficacy of using NSAIDS or colchicine for the treatment of acute gout flares
3. Recognize the utility of physical therapy for the treatment of chronic knee OA

Disclosures

Drs. Sternberg and Ganatra report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Watto MF, Ganatra RB, Sternberg M, Williams PN, Brigham SK. “#255 Hotcakes: Colchicine for CAD, and Gout flares, PT versus Steroids for Knee OA”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date February 8, 2021.