What is the initial management and treatment approach for a patient presenting with gouty arthritis?

Initial Management and Treatment Approach for Gouty Arthritis

Treatment of acute gouty arthritis should begin with NSAIDs, oral colchicine, or corticosteroids within 24 hours of symptom onset, with medication selection based on patient comorbidities and joint involvement. 1, 2

Acute Attack Management

First-Line Treatment Options:

1. NSAIDs (Evidence A)

   • Full anti-inflammatory doses until attack resolves 1, 2
   • Examples:
     • Indomethacin 50 mg three times daily until pain is tolerable 3
     • Naproxen at full anti-inflammatory doses 1
   • Continue until symptoms completely resolve 1
   • Caution: Avoid in renal disease, heart failure, or history of GI ulcers 2

2. Oral Colchicine (Evidence A)

   • Low-dose regimen: 1.2 mg loading dose, followed by 0.6 mg one hour later 1, 2
   • Then 0.6 mg once or twice daily until attack resolves 2
   • Most effective when started within 36 hours of symptom onset 1
   • Caution: Reduce dose in renal/hepatic impairment 1

3. Corticosteroids (Evidence A)

   • Oral prednisone/prednisolone: 0.5 mg/kg/day for 5-10 days 1, 2
   • Alternative regimen: 2-5 days at full dose, then taper for 7-10 days 1
   • Intra-articular injection for 1-2 joint involvement 1
   • Intramuscular triamcinolone acetonide 60 mg as alternative 1

Treatment Selection Based on Joint Involvement:

• 1-2 joints: Consider intra-articular corticosteroid injections (Evidence B) 1
• Polyarticular involvement (≥4 joints or ≥3 large joints): Systemic therapy preferred 1
• Severe attacks (pain ≥7/10 or polyarticular): Consider combination therapy 1

Combination Therapy for Severe Attacks:

• Colchicine + NSAIDs
• Oral corticosteroids + colchicine
• Intra-articular steroids with any other modality 1

For NPO Patients:

• Intra-articular corticosteroid injection for 1-2 joints 1
• IV/IM methylprednisolone (0.5-2.0 mg/kg) 1
• Subcutaneous ACTH (25-40 IU) 1

Monitoring Response

• Inadequate response is defined as:

  • <20% improvement in pain within 24 hours, OR
  • <50% improvement in pain ≥24 hours after starting therapy 1

• If inadequate response:

  1. Consider alternative diagnoses
  2. Switch to another monotherapy
  3. Add a second agent 1

Prophylaxis During Urate-Lowering Therapy

• Start prophylaxis with or just prior to initiating urate-lowering therapy 1, 2

• First-line options:

  • Low-dose colchicine: 0.6 mg once or twice daily 1, 2
  • Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI if indicated 1

• Second-line option:

  • Low-dose prednisone/prednisolone (<10 mg/day) 1

• Duration of prophylaxis:

  • At least 6 months, OR
  • 3 months after achieving target serum urate (if no tophi), OR
  • 6 months after achieving target serum urate (if tophi present) 1

Important Principles

• Do not interrupt urate-lowering therapy during an acute attack 1
• When initiating allopurinol, start with 100 mg daily and increase by 100 mg weekly until target serum urate <6 mg/dL is reached (maximum 800 mg/day) 4
• Maintain fluid intake of at least 2 liters daily to prevent urate crystal formation 4
• Consider comorbidities when selecting treatment:
  • Renal impairment: Avoid NSAIDs, adjust colchicine dose, prefer corticosteroids 5
  • Diabetes/hypertension: Consider NSAIDs or colchicine over corticosteroids 2
  • GI issues: Avoid NSAIDs, prefer corticosteroids or colchicine 2

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset reduces efficacy 1
• Failing to continue prophylaxis for adequate duration when starting urate-lowering therapy 1
• Interrupting urate-lowering therapy during acute attacks 1
• Using fixed-dose allopurinol rather than titrating to achieve target serum urate 4
• Overlooking drug interactions with colchicine, especially in patients with renal impairment 2

By following this algorithmic approach to gouty arthritis management, clinicians can effectively control acute attacks, prevent recurrences, and improve long-term outcomes for patients with gout.