What is the management of acute gout?

From the Guidelines

The management of acute gout should focus on rapid pain relief and reduction of inflammation, with first-line treatment including NSAIDs, colchicine, or corticosteroids, as recommended by the American College of Physicians 1. The choice of treatment should be based on the presence of contraindications, the patient's previous experience with treatments, and the number and type of joints involved.

• NSAIDs such as naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 5-7 days are effective options.
• Colchicine is another effective option, given as 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve, with low-dose colchicine being as effective as high-dose colchicine and causing fewer gastrointestinal adverse events 1.
• For patients with contraindications to NSAIDs or colchicine, oral corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) can be used. During an acute attack, patients should rest the affected joint, apply ice for 20 minutes several times daily, and maintain adequate hydration. Importantly, urate-lowering therapy (like allopurinol) should not be initiated during an acute attack as it may worsen symptoms, but existing therapy should be continued 1. Dietary modifications include limiting alcohol (especially beer), purines (organ meats, shellfish), and fructose-rich foods, with low-fat dairy products and regular exercise being encouraged 1. These treatments work by inhibiting inflammatory pathways triggered by urate crystal deposition in joints, with NSAIDs blocking prostaglandin synthesis, colchicine preventing neutrophil activation, and corticosteroids suppressing multiple inflammatory mediators.

From the FDA Drug Label

In patients with acute gout, a favorable response to naproxen was shown by significant clearing of inflammatory changes (e.g., decrease in swelling, heat) within 24 to 48 hours, as well as by relief of pain and tenderness. The management of acute gout involves the use of naproxen, which has been shown to provide relief from pain and tenderness, as well as reduce inflammatory changes, within 24 to 48 hours 2.

• Key points:
  • Naproxen is effective in managing acute gout
  • Relief from pain and tenderness can be expected within 24 to 48 hours
  • Naproxen reduces inflammatory changes, such as swelling and heat Note that allopurinol is not typically used for the management of acute gout, but rather for the prevention of future attacks and the reduction of serum uric acid levels 3, 3.

From the Research

Management of Acute Gout

The management of acute gout involves the use of various medications to reduce pain and inflammation.

• Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout, as stated in 4 and 5.
• These medications are equally efficacious, and the choice of medication is guided by comorbidities, according to 4.
• Allopurinol is an effective treatment for reducing concentrations of uric acid, with the starting dose guided by renal function and the maintenance dose guided by baseline serum uric acid concentration, as mentioned in 4.
• Febuxostat is another xanthine oxidase inhibitor that is clinically equivalent to allopurinol, as stated in 4.
• Uricosuric drugs, such as probenecid, increase uric acid excretion and may be used in the management of acute gout, according to 4 and 5.

Treatment Options

The following treatment options are available for acute gout:

• NSAIDs: effective in reducing pain and inflammation, but may have adverse effects, especially in the elderly, as mentioned in 5 and 6.
• Colchicine: effective in reducing pain and inflammation, but may have toxicity, as stated in 5 and 7.
• Corticosteroids: effective in reducing pain and inflammation, and may be used orally or intra-articularly, according to 5 and 8.
• Allopurinol: effective in reducing uric acid concentrations, but may not be suitable for all patients, as mentioned in 4 and 7.
• Febuxostat: an alternative to allopurinol, with similar efficacy, as stated in 4.
• Uricosuric drugs: increase uric acid excretion, but may not be suitable for all patients, according to 4 and 5.

Prophylaxis for Acute Gout Flares

Prophylaxis for acute gout flares is an important consideration in gout management, as stated in 7.

• Low-dose colchicine and low-dose NSAIDs are recommended as first-line therapies for prophylaxis, according to 7.
• Low-dose corticosteroids may be used as an alternative, but are not recommended as a first-line therapy, as mentioned in 7.
• IL-1 inhibitors, such as canakinumab and rilonacept, may be effective in preventing flares, but are not currently approved for this indication, as stated in 7.