From the Guidelines
The initial treatment for acute gout in the first toe should be started as soon as possible, with options including NSAIDs, colchicine, or corticosteroids, depending on patient factors, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
Treatment Options
- For most patients without contraindications, an NSAID like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 5-7 days is recommended.
- Alternatively, colchicine can be given as a loading dose of 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
- For patients with contraindications to these medications, oral prednisone (30-40mg daily for 3-5 days, then tapered) or intra-articular corticosteroid injection may be used.
Supportive Measures
- Rest, elevation of the affected foot, and ice application for 20 minutes several times daily can help reduce pain and swelling.
- Avoiding alcohol and purine-rich foods during the acute attack is also recommended.
Mechanism of Action
- These treatments work by reducing inflammation - NSAIDs inhibit prostaglandin synthesis, colchicine prevents neutrophil activation and migration, and corticosteroids suppress multiple inflammatory pathways.
Importance of Early Treatment
- Treatment should begin as soon as possible after symptom onset, as early intervention leads to faster resolution of pain and swelling, as emphasized by the 2020 American College of Rheumatology guideline for the management of gout 1.
From the FDA Drug Label
The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. The initial treatment for a patient presenting with gout in the first toe is 1.2 mg of colchicine (two tablets) at the first sign of the flare, followed by 0.6 mg (one tablet) one hour later 2.
- The maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period.
- Higher doses have not been found to be more effective.
From the Research
Initial Treatment for Gout in the First Toe
The initial treatment for a patient presenting with gout in the first toe typically involves managing the acute inflammation and pain.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or colchicine are commonly used to treat acute gout flares 3, 4, 5.
- Colchicine is often used at a low dose to prevent gout flares when initiating urate-lowering therapies, with studies suggesting that low-dose colchicine can be as effective as regular-dose colchicine in preventing flares while having fewer adverse events 6.
- Lifestyle modifications, such as limiting the consumption of purine-rich foods and avoiding alcoholic drinks, can also help reduce the likelihood of recurrent flares 3.
Urate-Lowering Therapies
For the prevention of recurrent gout, urate-lowering therapies are recommended.
- Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 3, 4, 5.
- Uricosuric agents, such as probenecid, can be used as adjuncts to urate-lowering therapies 4.
- Emerging therapies, including novel uricosurics and IL-1β antagonists, are being developed for the treatment of gout 4, 5.
Considerations for Treatment
When selecting a treatment for gout, considerations should be made for the patient's comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 4, 5.
- The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan can increase urinary excretion of uric acid 3.
- Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares 3.