What is the recommended treatment for gout (gouty arthritis) in the knee in males over 50?

Treatment of Gout in the Knee in Males Over 50

For acute gout attacks in the knee in males over 50, first-line treatment should include NSAIDs (such as naproxen or indomethacin), oral colchicine, or corticosteroids, with treatment initiated within 24 hours of symptom onset for optimal outcomes. 1

Acute Gout Attack Management

First-Line Treatment Options

1. NSAIDs:

   • Use full FDA-approved anti-inflammatory/analgesic doses 1
   • FDA-approved options for acute gout:
     • Naproxen
     • Indomethacin (25-50mg three times daily)
     • Sulindac
   • Continue at full dose until attack completely resolves 1
   • Caution: Consider renal function, cardiovascular risk, and GI risk in men over 50

2. Oral Colchicine:

   • Only effective if started within 36 hours of symptom onset 1
   • Modern dosing regimen: 1.2mg initially, followed by 0.6mg one hour later 1
   • After 12 hours, may continue with 0.6mg once or twice daily until attack resolves
   • Lower doses required in renal impairment and with certain drug interactions

3. Corticosteroids:

   • Oral: Prednisone 0.5mg/kg per day for 5-10 days 1
   • Intra-articular: Particularly effective for knee involvement
   • Intramuscular: Triamcinolone acetonide 60mg as an alternative 1

Treatment Selection Factors

• Choose based on:

  • Comorbidities (common in men over 50)
  • Previous response to therapy
  • Time since onset of attack
  • Patient preference

• For severe attacks or inadequate response to monotherapy:

  • Consider combination therapy (e.g., colchicine + NSAIDs or colchicine + corticosteroids) 1
  • Avoid combining NSAIDs with systemic corticosteroids due to increased GI toxicity

Long-Term Management

Urate-Lowering Therapy (ULT)

• Allopurinol is the standard first-line ULT:

  • Start at low dose (100mg daily)
  • Increase by 100mg weekly until target serum uric acid level ≤6mg/dL is achieved 2
  • Maximum dose: 800mg per day
  • Dose adjustment required in renal impairment

• Important: Do NOT interrupt ULT during an acute attack 1

Prophylaxis During ULT Initiation

• Always provide prophylaxis when starting ULT to prevent flares 1
• First-line prophylaxis options:
  • Low-dose colchicine: 0.6mg once or twice daily
  • Low-dose NSAIDs (e.g., naproxen 250mg twice daily) with PPI if indicated
• Second-line option:
  • Low-dose prednisone (<10mg/day) if colchicine and NSAIDs contraindicated
• Duration of prophylaxis:
  • At least 6 months, or
  • 3 months after achieving target serum urate if no tophi present
  • 6 months after achieving target serum urate if tophi present 1

Lifestyle Modifications

• Maintain adequate hydration (>2L daily) 2
• Slightly alkaline urine preferred to prevent urate precipitation 2
• Limit alcohol consumption, especially beer
• Avoid high-fructose corn syrup beverages

Important Considerations and Pitfalls

1. Do not delay treatment - initiate within 24 hours of symptom onset for best results 1

2. Expect flares when initiating ULT - this is normal and does not indicate treatment failure; continue ULT and treat the flare 3

3. Monitor renal function - especially important in older males using NSAIDs or allopurinol 2

4. Drug interactions - colchicine has significant interactions with CYP3A4 inhibitors and P-glycoprotein inhibitors, requiring dose adjustment 1

5. Avoid undertreatment - inadequate dosing of ULT is a common pitfall; titrate to reach target uric acid level rather than using fixed doses 2

6. Continue prophylaxis for the recommended duration to prevent painful flares during the urate mobilization phase 1