From the Guidelines
The most effective treatment for gout in the emergency department is corticosteroids, which should be considered as first-line therapy in patients without contraindications due to their safety and low cost. According to the American College of Physicians guideline 1, high-quality evidence supports the use of corticosteroids, NSAIDs, and colchicine to reduce pain in patients with acute gout.
Treatment Options
- Corticosteroids, such as prednisolone at a dose of 35 mg for 5 days, are a safe and effective treatment option for acute gout, with fewer adverse effects compared to NSAIDs 1.
- NSAIDs, including indomethacin, naproxen, and ibuprofen, are also effective in reducing pain and inflammation, but may have adverse effects such as dyspepsia and gastrointestinal perforations, ulcers, and bleeding 1.
- Colchicine is an alternative option for patients with contraindications to NSAIDs, but is more expensive and may have adverse effects such as gastrointestinal issues and headache 1.
Important Considerations
- Patients with systemic fungal infections or known contraindications should not receive corticosteroids 1.
- Patients with renal disease, heart failure, or cirrhosis may have contraindications to NSAIDs 1.
- Colchicine is contraindicated in patients with renal or hepatic impairment who are using potent cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors 1.
Supportive Measures
- Joint rest, ice application, and elevation are important supportive measures to reduce pain and inflammation.
- Patients should be advised to maintain adequate hydration and avoid alcohol and purine-rich foods during the acute attack.
- Continuing any existing urate-lowering therapy during the attack is crucial, as stopping can worsen symptoms 1.
From the FDA Drug Label
Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis
- Treatment of gout in the ED: Indomethacin is effective in relieving the symptoms of acute gouty arthritis.
- Key points:
- Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) that exhibits antipyretic and analgesic properties.
- It is a potent inhibitor of prostaglandin synthesis, which contributes to its therapeutic effects.
- Indomethacin has been shown to be effective in relieving pain, reducing fever, swelling, redness, and tenderness of acute gouty arthritis 2.
From the Research
Treatment of Gout in the Emergency Department
- The treatment of gout in the emergency department (ED) is largely consistent with guideline recommendations, with non-steroidal anti-inflammatory drugs (NSAIDs) being the mainstay of treatment 3, 4.
- However, there is evidence to suggest that NSAIDs may not be given during ED visits in over 50% of cases 4.
- Colchicine, oral or intramuscular corticosteroids, and IL-1 inhibitors are also effective options for treating acute gout flares 5, 6, 7.
- Urate-lowering therapies, such as allopurinol and febuxostat, are used to prevent gout flares, with an emphasis on a treat-to-target strategy 5.
Diagnostic Procedures
- Diagnostic blood analysis and X-ray of the affected joint are commonly performed in the ED, but there is evidence to suggest that X-rays are often performed without a correct indication 3.
- Arthrocentesis is performed in a small percentage of cases to demonstrate monosodium urate monohydrate (MSU) crystals 3, 4.
- Clinical diagnostic scores are recommended for diagnosing acute gout, rather than relying on diagnostic procedures alone 3.
Pharmacological Treatment
- NSAIDs are effective for treating acute gout, but may have little to no effect on function, inflammation, or adverse events 6.
- COX-2 inhibitors and non-selective NSAIDs are probably equally beneficial in terms of pain relief and improvement in function, but non-selective NSAIDs may increase withdrawals due to adverse events and total adverse events 6.
- Systemic glucocorticoids and NSAIDs are probably equally beneficial in terms of pain relief, improvement in function, and treatment success, but NSAIDs may result in more total adverse events 6.