What is the recommended treatment for acute gout?

Treatment of Acute Gout

Corticosteroids should be considered as first-line therapy for acute gout in patients without contraindications because they are generally safer and a low-cost treatment option with effectiveness comparable to NSAIDs but fewer adverse effects. 1

First-Line Treatment Options

The American College of Physicians (ACP) strongly recommends three effective first-line medication options for treating acute gout attacks:

1. Corticosteroids

   • Preferred first-line option due to safety profile and cost 1
   • Oral: Prednisolone 35 mg daily for 5 days 1
   • Intra-articular: Dose varies by joint size 1
   • Intramuscular: Triamcinolone acetonide 60 mg 1, 2
   • Duration: 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 1

2. NSAIDs

   • Use full FDA/EMA-approved anti-inflammatory doses 1
   • FDA-approved options: naproxen, indomethacin, sulindac 1
   • Continue at full dose until attack resolves completely 1
   • Contraindicated in patients with renal disease, heart failure, or cirrhosis 1

3. Colchicine

   • Low-dose regimen: 1.2 mg followed by 0.6 mg one hour later 1, 3
   • More expensive than NSAIDs or corticosteroids despite generic availability 1
   • Start within 36 hours of symptom onset for best efficacy 1
   • Contraindicated in patients with renal/hepatic impairment taking CYP3A4 or P-glycoprotein inhibitors 1, 3

Treatment Selection Algorithm

Step 1: Assess severity and extent of gout attack

• Mild/moderate pain (≤6/10) with 1-3 small joints or 1-2 large joints: Use monotherapy 1
• Severe pain or polyarticular attack (≥4 joints or ≥3 large joints): Consider combination therapy 1

Step 2: Consider patient-specific factors

• Prefer corticosteroids if:

  • No contraindications (systemic fungal infections) 1
  • History of GI issues with NSAIDs
  • Renal impairment, heart failure, or cirrhosis 1, 4

• Prefer NSAIDs if:

  • No contraindications
  • Previous good response
  • No history of GI issues

• Prefer colchicine if:

  • Started within 36 hours of symptom onset 1
  • No renal/hepatic impairment
  • No interacting medications

Step 3: Special considerations

• Cardiovascular disease/heart failure: Colchicine is safest option, avoid NSAIDs 4
• Renal impairment: Corticosteroids preferred; adjust colchicine dose if used 3
• Hepatic impairment: Corticosteroids preferred; adjust colchicine dose if used 3

Important Clinical Pearls

1. Initiate treatment early: Start therapy within 24 hours of symptom onset for optimal outcomes 1

2. Continue urate-lowering therapy: Do not interrupt ongoing urate-lowering therapy during an acute attack 1

3. Dose adjustments:

   • For colchicine in renal impairment: Reduce dose in severe impairment (CrCl <30 mL/min) to 0.3 mg/day 3
   • For colchicine with strong CYP3A4 inhibitors: Reduce dose by 50% or avoid 3

4. Combination therapy for severe attacks:

   • Consider combining treatment modalities for severe or polyarticular attacks 1
   • Example: Colchicine plus corticosteroids

Common Pitfalls to Avoid

1. Stopping urate-lowering therapy during acute attacks - This can worsen outcomes 1

2. Using high-dose colchicine regimens - Low-dose colchicine is equally effective with fewer adverse effects 1

3. Delaying treatment - Early intervention leads to better outcomes 1

4. Using NSAIDs in patients with cardiovascular disease - Increases risk of adverse cardiovascular events 4

5. Failing to adjust colchicine dosing - Must be adjusted for renal/hepatic impairment and drug interactions 3

By following these evidence-based recommendations and considering patient-specific factors, acute gout attacks can be effectively managed while minimizing adverse effects and complications.