From the Guidelines
The acute management of gout in the knee should involve the use of corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout, as recommended by the American College of Physicians (1). The choice of medication depends on the patient's medical history, contraindications, and potential harms.
- Corticosteroids, such as oral prednisone (30-40mg daily, tapered over 7-10 days) or an intra-articular injection of methylprednisolone (40-80mg), are effective options for patients without contraindications.
- NSAIDs, such as naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days, are also first-line treatments.
- Colchicine can be used at 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve, especially in patients with contraindications to NSAIDs or corticosteroids (2). Supportive measures, such as rest, ice application for 20 minutes several times daily, and elevation of the affected knee, can help reduce inflammation and pain. Adequate hydration is important to help excrete uric acid. During the acute attack, patients should continue any existing urate-lowering therapy but should not initiate new therapy until the acute attack resolves (typically 1-2 weeks) (3). These interventions work by reducing inflammation caused by urate crystal deposition in the joint, with NSAIDs inhibiting prostaglandin synthesis, colchicine preventing neutrophil activation, and corticosteroids suppressing multiple inflammatory pathways (4). It is essential to discuss the benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks (5).
From the FDA Drug Label
Acute gouty arthritis. Suggested Dosage: Indomethacin capsules 50 mg t.i.d. until pain is tolerable. The dose should then be rapidly reduced to complete cessation of the drug. Definite relief of pain has been reported within 2 to 4 hours. Tenderness and heat usually subside in 24 to 36 hours, and swelling gradually disappears in 3 to 5 days.
The acute management for gout knee using indomethacin is to take 50 mg of indomethacin capsules three times a day until the pain is tolerable, then rapidly reduce the dose to complete cessation of the drug 6.
- Key points:
- Initial dose: 50 mg t.i.d.
- Duration: until pain is tolerable
- Reduction: rapidly reduce to complete cessation of the drug after pain is tolerable
- Relief: definite relief of pain within 2 to 4 hours
- Resolution: tenderness and heat subside in 24 to 36 hours, swelling disappears in 3 to 5 days
From the Research
Acute Management for Gout Knee
- The mainstays of acute gout management are colchicine, NSAIDs, and systemic or intra-articular corticosteroids 7.
- NSAIDs are preferable to colchicine because of their more favorable side effect profile 7.
- Successful treatment occurs with the prompt initiation of high dose short half-life NSAIDS 7.
- Systemic corticosteroids are commonly used to treat acute gouty arthritis, especially in patients with comorbidities that preclude the use of NSAIDS or colchicine 7, 8.
- Intra-articular injections are appropriate in the setting of mono- or oligoarticular involvement 7.
- Low-dose colchicine has a comparable tolerability profile to placebo and a significantly lower side effect profile compared to high-dose colchicine 8.
- IL-1 inhibitors, such as canakinumab, are effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 8, 9.
Treatment Options
- NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks 8.
- Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs 8, 9.
- Colchicine is effective, with low-dose colchicine being safer than high-dose colchicine 8, 9.
- ACTH is suggested to be efficacious in acute gout 8.
- Canakinumab is effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 8, 9.
Prevention and Prophylaxis
- Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating any urate-lowering therapy in order to prevent acute gouty arthritis for a period of at least 6 months 10.
- Xanthine oxidase inhibitor therapy remains the consensus first-line treatment option for the prevention of recurrent gout 10.
- Add-on therapies that reduce serum urate concentration include traditional uricosuric agents and a novel uric acid reabsorption inhibitor 10.