What is the treatment for suspected gout?

Treatment of Suspected Gout

For suspected gout, first-line treatment should be oral colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs, or corticosteroids, with the choice based on patient-specific contraindications and comorbidities. 1

Acute Gout Attack Management

First-Line Treatment Options

1. Colchicine:

   • Low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later 2
   • Must be started within 12-24 hours of symptom onset for maximum effectiveness 1
   • Avoid in patients with severe renal impairment or those taking strong P-glycoprotein/CYP3A4 inhibitors 1
   • Low-dose regimen has similar efficacy to high-dose with fewer adverse effects (particularly gastrointestinal) 1

2. NSAIDs:

   • Use full anti-inflammatory doses 1
   • Options include naproxen (500 mg twice daily), indomethacin (50 mg three times daily) 1, 3
   • Contraindicated in renal disease, heart failure, cirrhosis, or history of GI bleeding 1
   • Consider adding proton pump inhibitor for GI protection 1

3. Corticosteroids:

   • Oral: Prednisolone 30-35 mg daily for 3-5 days 1
   • Intra-articular: Particularly useful for monoarticular gout 1
   • Intramuscular: Triamcinolone acetonide 60 mg 1
   • Good option for patients with contraindications to NSAIDs or colchicine 1

Treatment Selection Algorithm

1. For mild-moderate attacks (≤6/10 pain, 1-3 small joints or 1-2 large joints):

   • Choose monotherapy based on:
     • If no contraindications: Corticosteroids (preferred due to safety profile and cost) 1
     • If rapid onset needed within 12 hours: Colchicine 1
     • If patient has history of good response: Use previously effective agent 1

2. For severe attacks (>6/10 pain or polyarticular):

   • Consider combination therapy (e.g., colchicine plus NSAID or corticosteroid) 1

3. For patients with comorbidities:

   • Renal impairment: Avoid colchicine and NSAIDs; use corticosteroids 1
   • Diabetes: NSAIDs or colchicine preferred over corticosteroids
   • GI issues: Avoid NSAIDs; use colchicine or corticosteroids 1

Important Clinical Pearls

• Begin treatment as early as possible, ideally within 24 hours of symptom onset 1
• Continue any existing urate-lowering therapy during the acute attack 1
• Educate patients to self-medicate at the first warning symptoms 1
• Avoid high-dose colchicine regimens (>1.8 mg in 24 hours) due to significant toxicity 1
• Monitor for adverse effects:
  • Colchicine: Diarrhea, nausea, vomiting
  • NSAIDs: GI bleeding, renal dysfunction, cardiovascular events
  • Corticosteroids: Hyperglycemia, mood changes, fluid retention

Long-Term Management

After treating the acute attack, consider:

1. Urate-lowering therapy (ULT) for patients with:

   • Recurrent attacks
   • Tophi
   • Joint damage
   • Renal stones
   • Very high serum urate (>8 mg/dL) 1

2. Flare prophylaxis when starting ULT:

   • Colchicine 0.5-1 mg daily
   • Low-dose NSAIDs
   • Continue for 6 months after initiating ULT 1, 4

3. Lifestyle modifications:

   • Weight loss if overweight
   • Limit alcohol (especially beer)
   • Avoid sugar-sweetened drinks
   • Limit purine-rich foods (organ meats, shellfish)
   • Encourage low-fat dairy products 1, 5

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset
• Using high-dose colchicine regimens (associated with severe GI toxicity)
• Stopping urate-lowering therapy during an acute attack
• Failing to provide prophylaxis when initiating urate-lowering therapy
• Misdiagnosing septic arthritis as gout (consider joint aspiration if uncertain)

Remember that early intervention is key to successful management of acute gout attacks, and treatment should be tailored based on the patient's comorbidities and contraindications to specific medications.