What is the treatment for symptoms of gout within the knee joint?

Treatment of Gout in the Knee Joint

For acute gout attacks in the knee joint, first-line treatment options include NSAIDs, oral colchicine, or corticosteroids, with treatment initiated within 24 hours of symptom onset for optimal outcomes. 1

Initial Management of Acute Gout in the Knee

First-Line Treatment Options

1. NSAIDs

   • Use full FDA-approved doses until the attack completely resolves 1
   • Options include:
     • Naproxen (FDA-approved for gout)
     • Indomethacin (FDA-approved for gout) 2
     • Sulindac (FDA-approved for gout)

2. Oral Colchicine

   • Most effective when started within 36 hours of symptom onset 1
   • Dosing regimen: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 3
   • Maximum dose: 1.8 mg over a one-hour period 3

3. Corticosteroids

   • Options include:
     • Oral: Prednisone 0.5 mg/kg per day for 5-10 days 1
     • Intra-articular: Particularly effective for monoarticular gout in the knee 1
     • Intramuscular: Triamcinolone acetonide 60 mg 1

Treatment Selection Considerations

• For the knee joint specifically: Intra-articular corticosteroid injection may provide rapid relief when only the knee is affected
• For patients with contraindications to NSAIDs (e.g., renal impairment, history of GI bleeding):
  • Use colchicine or corticosteroids 1
• For patients with contraindications to colchicine (e.g., severe renal/hepatic impairment):
  • Use NSAIDs or corticosteroids 1

Management of Inadequate Response

If inadequate response to initial therapy (defined as <20% improvement in pain within 24 hours or <50% improvement at 24 hours) 1:

1. Switch to an alternative monotherapy from a different class
2. Consider combination therapy:
   • NSAID + colchicine
   • Oral corticosteroid + colchicine
   • Intra-articular steroid + either NSAID or colchicine

Long-Term Management After Acute Attack

Urate-Lowering Therapy (ULT)

• Important: Continue any established ULT during the acute attack without interruption 1
• After resolution: Consider initiating ULT if patient has:
  • Recurrent attacks (≥2 per year)
  • Tophi
  • Joint damage
  • Chronic kidney disease
  • History of urolithiasis 4

Prophylaxis When Starting ULT

• Initiate prophylaxis with or just prior to starting ULT 1
• First-line prophylaxis options:
  • Low-dose colchicine: 0.6 mg once or twice daily 3
  • Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) 1
• Duration of prophylaxis:
  • At least 6 months, or
  • 3 months after achieving target serum urate if no tophi are present
  • 6 months after achieving target serum urate if tophi are present 1

Common Pitfalls and Caveats

1. Delayed treatment: Initiate treatment within 24 hours of symptom onset for best results 1
2. Interrupting ULT: Never discontinue ongoing ULT during an acute attack as this can worsen and prolong the attack 1
3. Inadequate prophylaxis: Failure to provide prophylaxis when initiating ULT often leads to flares 1
4. Incorrect colchicine dosing: Modern colchicine dosing is lower than historical regimens; high doses increase toxicity without improving efficacy 3
5. Overlooking drug interactions: Colchicine requires dose adjustment when used with CYP3A4 and P-glycoprotein inhibitors 3

Lifestyle Modifications

While treating the acute attack, advise patients to:

• Limit consumption of purine-rich foods (organ meats, shellfish)
• Avoid alcoholic drinks, especially beer
• Avoid beverages sweetened with high-fructose corn syrup
• Encourage consumption of vegetables and low-fat dairy products 5

By following this structured approach to treating gout in the knee joint, you can effectively manage acute attacks, prevent recurrences, and improve long-term outcomes for patients with this painful condition.