What is the treatment for an acute gout attack in an inpatient setting?

From the Guidelines

The treatment for an acute gout attack in an inpatient setting should involve prompt administration of anti-inflammatory medications, with corticosteroids being considered as first-line therapy in patients without contraindications, due to their effectiveness and relatively safer profile compared to NSAIDs and colchicine 1.

Key Considerations

• The choice of medication depends on patient comorbidities, with NSAIDs avoided in renal impairment or GI bleeding risk, colchicine dose-reduced in renal impairment, and corticosteroids used cautiously in diabetic patients due to potential glucose elevation.
• Corticosteroids, such as prednisolone at a dose of 35 mg for 5 days, have been shown to be effective in treating acute gout with fewer adverse effects compared to NSAIDs 1.
• NSAIDs, including indomethacin, naproxen, and ibuprofen, are also effective options, but their use should be tailored based on the patient's renal function and risk of gastrointestinal complications.
• Colchicine is another option, but its use is limited by its potential for gastrointestinal side effects and interactions with other medications, such as strong P-glycoprotein and/or CYP3A4 inhibitors 1.

Treatment Approach

• Treatment should begin within 24 hours of symptom onset for maximum effectiveness, as delays can prolong the attack.
• Intra-articular steroid injections may be used if only one or two joints are affected and the patient has contraindications to systemic medications.
• Adequate hydration, joint rest, and ice application are important supportive measures to help manage symptoms.
• Urate-lowering therapy should not be initiated during an acute attack but can be continued if the patient is already taking it, with the goal of maintaining a serum uric acid level <6 mg/dL (360 mmol/L) 1.

From the Research

Treatment Options for Acute Gout Attack in Inpatient Setting

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for the treatment of acute gout, but caution is required in view of their adverse effects, especially in the elderly 2
• Colchicine is still an effective acute agent, but care must be taken to monitor toxicity 2
• Intra-articular glucocorticosteroid therapy is useful and very safe; oral steroids and corticotrophin (adrenocorticotrophic hormone) may have a small role in acute therapy and seem safe when used over short time spans 2
• Low dose colchicine may have a cost and toxicity advantage over NSAIDs in the prophylaxis of gout when commencing therapy aimed at reducing elevated plasma urate concentrations 2

Efficacy of Different Treatment Options

• NSAIDs may improve pain at 24 hours and may have little to no effect on function, inflammation, or adverse events for treatment of acute gout 3
• COXIBs and non-selective NSAIDs are probably equally beneficial with regards to improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs probably increase withdrawals due to adverse events and total adverse events 3
• Systemic glucocorticoids and NSAIDs probably are equally beneficial in terms of pain relief, improvement in function, and treatment success 3, 4
• Oral colchicine demonstrated to be effective, with low-dose colchicine demonstrating a comparable tolerability profile as placebo and a significantly lower side effect profile to high-dose colchicine 5

Treatment Patterns in Hospitalized Patients

• The most widely used drugs for acute gout were colchicine and nonsteroidal antiinflammatory drugs (NSAID) 6
• Combination therapy was used in 52% of patients with acute gout 6
• Renal failure was present in 73% of patients with acute gout, and colchicine and NSAID should therefore be used with caution in these patients 6