What is the initial treatment for acute gout?

Initial Treatment for Acute Gout

The initial treatment for acute gout should be started within 24 hours of symptom onset and includes NSAIDs, colchicine, or corticosteroids, with the choice depending on patient-specific factors and comorbidities. 1

First-Line Treatment Options

NSAIDs

• Dosing: Full FDA-approved anti-inflammatory doses
• FDA-approved options:
  • Naproxen
  • Indomethacin
  • Sulindac
• Duration: Continue at full dose until attack completely resolves
• Contraindications: Renal disease, heart failure, cirrhosis
• Common adverse effects: Dyspepsia, GI bleeding, ulceration

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Maximum dose: 1.8 mg over a one-hour period
• Timing: Most effective when started within 36 hours of symptom onset 1
• Contraindications: Severe renal/hepatic impairment, patients taking CYP3A4/P-glycoprotein inhibitors
• Common adverse effects: Diarrhea, nausea, vomiting, abdominal pain

Corticosteroids

• Oral options:
  • Prednisone 0.5 mg/kg per day for 5-10 days then stop, OR
  • 2-5 days at full dose then taper for 7-10 days
  • Methylprednisolone dose pack
• Alternative routes:
  • Intra-articular: Dose varies by joint size
  • Intramuscular: Triamcinolone acetonide 60 mg
• Contraindications: Systemic fungal infections
• Common adverse effects: Dysphoria, elevated blood glucose, fluid retention

Treatment Selection Algorithm

1. For patients with no contraindications to any therapy:

   • Consider corticosteroids as first-line (safer and lower cost) 1
   • NSAIDs are equally effective but have more adverse effects
   • Low-dose colchicine is effective but more expensive

2. For patients with renal impairment:

   • Avoid NSAIDs
   • Consider dose-adjusted colchicine or corticosteroids

3. For patients with GI risk factors:

   • Avoid NSAIDs or use with gastroprotection
   • Consider colchicine or corticosteroids

4. For patients with diabetes:

   • NSAIDs or colchicine preferred over corticosteroids
   • If corticosteroids necessary, monitor blood glucose closely

5. For NPO (nil per os) patients:

   • Intra-articular corticosteroids for 1-2 affected joints
   • Parenteral corticosteroids for polyarticular involvement

Special Considerations

• Severe or polyarticular attacks: Consider combination therapy with two agents at full doses (e.g., colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality) 1

• Inadequate response: Defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours. Consider:

  • Switching to alternative monotherapy
  • Adding a second agent
  • Reevaluating diagnosis

• Ongoing urate-lowering therapy: Do not interrupt during acute attacks 1

Common Pitfalls to Avoid

1. Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness
2. Using high-dose colchicine regimens, which cause more adverse effects without improved efficacy 1
3. Discontinuing urate-lowering therapy during an acute attack, which can worsen or prolong the attack 1
4. Failing to educate patients about initiating treatment at first signs of an attack
5. Using colchicine in patients with significant renal or hepatic impairment without appropriate dose adjustment

By promptly initiating appropriate anti-inflammatory therapy and considering patient-specific factors, acute gout attacks can be effectively managed to reduce pain, inflammation, and disability.