What is the treatment for gout?

Treatment of Gout

For acute gout attacks, first-line treatment options include NSAIDs, oral colchicine, or corticosteroids, with treatment initiated within 24 hours of symptom onset for optimal outcomes. 1, 2

Acute Gout Management Algorithm

First-Line Options (Choose one based on patient factors):

1. NSAIDs:

   • Use full FDA-approved anti-inflammatory doses until attack resolves
   • Examples: naproxen, indomethacin, sulindac (FDA-approved for gout)
   • Continue until attack completely resolves
   • Avoid in patients with renal disease, heart failure, or cirrhosis

2. Oral Colchicine:

   • Low-dose regimen: 1.2 mg loading dose, followed by 0.6 mg one hour later
   • Then 0.6 mg once or twice daily until attack resolves
   • Most effective when started within 36 hours of symptom onset
   • Dose adjustment required in renal impairment:
     • For severe renal impairment: Do not repeat treatment course more than once every two weeks
     • For dialysis patients: Reduce to single dose of 0.6 mg, do not repeat more than once every two weeks 3

3. Corticosteroids:

   • Oral prednisone: 0.5 mg/kg/day for 5-10 days then stop, OR
   • 2-5 days at full dose then taper for 7-10 days
   • Intra-articular option for 1-2 large joints (dose varies by joint size)
   • Intramuscular option: Triamcinolone acetonide 60 mg

Treatment Selection Based on Clinical Presentation:

For 1-2 joint involvement:

• Any first-line option appropriate
• Consider intra-articular steroids if accessible joints

For polyarticular gout (≥4 joints):

• Oral corticosteroids or full-dose NSAIDs preferred

For severe attacks (≥7/10 pain or polyarticular):

• Consider combination therapy:
  • Colchicine + corticosteroids
  • Colchicine + NSAIDs
  • Intra-articular steroids with any other modality

Patient-Specific Considerations

1. Renal impairment:

   • Prefer corticosteroids
   • Adjust colchicine dosing:
     • Severe impairment: Do not repeat treatment more than once every two weeks
     • Dialysis: Single dose of 0.6 mg, do not repeat more than once every two weeks 3
   • Avoid NSAIDs

2. Cardiovascular disease:

   • Prefer colchicine or corticosteroids
   • Avoid NSAIDs

3. Diabetes/uncontrolled hypertension:

   • Prefer NSAIDs or colchicine over corticosteroids

4. GI issues/history of ulcers:

   • Prefer corticosteroids or colchicine
   • Avoid NSAIDs

Long-Term Management

1. Urate-Lowering Therapy (ULT):

   • Continue ULT during acute attacks if already initiated
   • Do not start ULT during an acute attack
   • The American College of Physicians recommends against initiating long-term ULT after a first gout attack or in patients with infrequent attacks 1
   • For recurrent attacks, discuss benefits, harms, costs, and preferences before initiating ULT 1

2. Prophylaxis when starting ULT:

   • Colchicine 0.6 mg daily is recommended when starting ULT
   • Continue prophylaxis for 3-6 months
   • Low-dose NSAIDs are an alternative if colchicine is not tolerated

Common Pitfalls to Avoid

1. Inadequate dosing: Use full anti-inflammatory doses of NSAIDs, not just analgesic doses

2. Delayed treatment: Initiate treatment within 24 hours of symptom onset for best results

3. Stopping ULT during acute attacks: Continue ULT if already started

4. Failure to recognize inadequate response: If <20% improvement in pain within 24 hours or <50% improvement at 24 hours, consider alternative diagnosis or treatment

5. Ignoring drug interactions: Particularly with colchicine and CYP3A4 inhibitors

6. Overlooking renal function: Adjust colchicine dosing in renal impairment and avoid NSAIDs

7. Not providing prophylaxis when starting ULT: This can lead to increased flares initially

The evidence strongly supports equal efficacy between NSAIDs, colchicine, and corticosteroids for acute gout management 1, 4, 5, with treatment selection primarily guided by patient-specific factors and comorbidities. A randomized controlled trial demonstrated that oral prednisolone and naproxen are equally effective in treating acute gout 4, providing high-quality evidence for corticosteroids as a first-line option.