From the Guidelines
The recommended treatment for acute gout involves corticosteroids, NSAIDs, or colchicine as first-line options, with corticosteroids being considered as the 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 shows that these treatments are effective in reducing pain in patients with acute gout. The choice of treatment should be based on the presence of contraindications, patient's previous experience with treatments, and the number and type of joints involved, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
Some key points to consider when treating acute gout include:
- Starting treatment as soon as possible after symptom onset to lead to faster resolution
- Using corticosteroids, such as prednisolone at a dose of 35 mg for 5 days, as a first-line therapy in patients without contraindications
- Considering NSAIDs, such as indomethacin or naproxen, as alternative options, but being aware of their potential adverse effects, such as dyspepsia and gastrointestinal perforations
- Using colchicine, with a loading dose of 1 mg followed by 0.5 mg on day 1, as another alternative option, but being aware of its potential adverse effects, such as gastrointestinal issues
- Avoiding alcohol and purine-rich foods during an attack
- Providing additional relief through rest, ice application to the affected joint, and elevation
- Ensuring adequate hydration to help eliminate uric acid from the body
It is essential to weigh the benefits and harms of each treatment option and consider the individual patient's needs and contraindications when making a treatment decision, as recommended by the American College of Physicians guideline 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 maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period.
The recommended treatment for acute gout 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, with a maximum dose of 1.8 mg over a one-hour period 2.
- Key points:
- The dose should not be repeated more than once every 2 weeks in patients with severe renal impairment.
- For patients undergoing dialysis, the total recommended dose should be reduced to a single dose of 0.6 mg (one tablet).
- Treatment of gout flares with Colchicine Tablets, USP is not recommended in patients with renal impairment who are receiving Colchicine Tablets, USP for prophylaxis.
From the Research
Treatment Options for Acute Gout
The recommended treatment for acute gout includes:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) 3
- Colchicine, which is effective but requires careful monitoring of toxicity 3, 4, 5, 6
- Intra-articular glucocorticosteroid therapy, which is useful and safe 3
- Oral steroids and corticotrophin (adrenocorticotrophic hormone), which may have a small role in acute therapy and seem safe when used over short time spans 3, 7
Considerations for Treatment
When considering treatment options, it's essential to take into account the patient's comorbidities, such as cardiovascular disease, hypertension, renal dysfunction, or diabetes/metabolic syndrome, which may represent contraindications to certain therapeutic options 7.
- Colchicine has a low benefit-to-toxicity ratio and should be used as a second-line therapy when NSAIDs or corticosteroids are contraindicated or ineffective 5, 6
- Adrenocorticotropic hormone (ACTH) may be an alternative therapeutic option for gout in patients with multiple comorbidities, with a good safety profile and potential mechanisms of action that include downregulating inflammatory responses and IL-1 antagonistic effects 7
Efficacy and Safety of Treatment Options
Studies have shown that:
- Colchicine is effective in reducing pain and clinical symptoms in patients with acute gout, with an absolute reduction of 34% for pain and a 30% reduction in clinical symptoms 5
- The number needed to treat (NNT) with colchicine versus placebo to reduce pain is 3, and the NNT to reduce clinical symptoms is 2 5
- However, colchicine is associated with a high frequency of gastrointestinal adverse events, and all participants treated with colchicine experienced gastrointestinal side effects in one study 5