From the Guidelines
The recommended treatment for acute gout in the emergency department includes NSAIDs, colchicine, or corticosteroids as first-line options, with the choice of drug based on the presence of contraindications, patient's previous experience with treatments, and the number and type of joint(s) involved 1. When selecting a treatment, it is essential to consider the patient's medical history, current medications, and potential interactions. For NSAIDs, options such as naproxen 500mg twice daily or indomethacin 50mg three times daily for 5-7 days are effective 1. Colchicine can be given as 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily for 7-10 days, with a low-dose regimen recommended to minimize adverse effects 1. For patients with contraindications to these medications, oral prednisone 30-40mg daily for 3-5 days or a single intramuscular or intra-articular injection of methylprednisolone may be used 1.
Key considerations for treatment include:
- Patient education on self-medication at the first warning symptoms of a gout attack
- Avoidance of colchicine in patients with severe renal impairment or those receiving strong P-glycoprotein and/or CYP3A4 inhibitors
- Use of proton pump inhibitors with NSAIDs if appropriate
- Monitoring of serum uric acid levels and adjustment of treatment as needed
The discharge plan should include:
- Medication instructions and potential side effects
- Advice to rest and elevate the affected joint
- Adequate hydration and avoidance of alcohol and purine-rich foods
- Follow-up with the primary care provider within 1-2 weeks
- Instructions to return if symptoms worsen or new symptoms develop
Lifestyle modifications are also crucial in managing gout, including:
- Weight loss if appropriate
- Avoidance of alcohol, especially beer and spirits, and sugar-sweetened drinks
- Encouragement of low-fat dairy products and regular exercise
- Reduction of excessive intake of meat and seafood
By following these recommendations, patients with acute gout can effectively manage their symptoms, reduce the risk of future attacks, and improve their overall quality of life 1.
From the FDA Drug Label
The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage.
For acute gout treatment, the recommended dosage of allopurinol is 100 mg daily, increasing by 100 mg weekly until a serum uric acid level of 6 mg/dL or less is attained.
- The discharge plan from the emergency department for acute gout should include:
- Initiation of allopurinol at a low dose (100 mg daily) with gradual increase as needed and tolerated
- Monitoring of serum uric acid levels to ensure adequate control
- Patient education on dietary changes and lifestyle modifications to reduce the risk of recurrent gout attacks
- Follow-up appointment with a primary care physician or rheumatologist to continue management and adjust treatment as needed 2
From the Research
Acute Gout Treatment
- The recommended treatment for acute gout includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or corticosteroids, or a combination of two agents 3.
- Standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 4.
- Medications given during emergency department visits for acute gout include NSAIDs, opiates, colchicine, and prednisone 5.
Discharge Plan from the Emergency Department
- Acute gout rarely leads to hospitalizations, with most patients being discharged from the emergency department 5, 6.
- Patients with acute gout may be given further treatment recommendations, such as cryotherapy or diet, upon discharge from the emergency department 6.
- Urate-lowering therapy may be recommended as further therapy for patients with acute gout, with allopurinol and febuxostat being common treatment options 4, 7.
Considerations for Treatment and Discharge
- The treatment of acute gout should be personalized, taking into account comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 4.
- The diagnosis of acute gout is commonly clinical and not crystal-proven, with clinical scores being recommended for diagnosis 6.
- Patients with acute gout should be monitored for potential complications, such as superinfection or uncertain trauma, which may require additional diagnostic testing or treatment 6.