What is the recommended treatment for acute gout?

Treatment of Acute Gout

First-line treatment for acute gout should be initiated within 24 hours of symptom onset using NSAIDs, oral colchicine, or corticosteroids, with medication selection based on patient comorbidities and joint involvement. 1

First-Line Treatment Options

NSAIDs

• Use full FDA-approved anti-inflammatory doses until attack resolves 1
• Example: Naproxen at anti-inflammatory doses
• Contraindications: Avoid in patients with cardiovascular disease, heart failure, peptic ulcer disease, or renal failure 1, 2
• NSAIDs with short plasma half-lives (diclofenac, ketoprofen) are preferred in elderly patients 3

Colchicine

• Low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later 1
• Advantages: Safe in cardiovascular disease and may reduce risk of myocardial infarction 2
• Dose adjustments:
  • Reduce dose in renal impairment: For severe impairment (CrCl <30 mL/min), treatment course should not be repeated more than once every two weeks 4
  • Adjust dose with CYP3A4 inhibitors 4
• Poorly tolerated in elderly patients - use with caution 3

Corticosteroids

• Oral prednisone: 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 1
• Intra-articular corticosteroids: Dose varies by joint size 1
• Intramuscular triamcinolone acetonide 60 mg, followed by oral prednisone 1
• First choice in patients with renal disease, heart failure, cirrhosis, or contraindications to NSAIDs/colchicine 1
• Short durations of low-dose glucocorticoids are efficacious and may be safe in patients with cardiovascular disease 2

Treatment Selection Algorithm

1. For patients with renal disease, heart failure, or cirrhosis:

   • First choice: Corticosteroids 1
   • Avoid NSAIDs 1, 2
   • Adjust colchicine dose if used 4

2. For patients with cardiovascular disease:

   • First choice: Colchicine (may have cardioprotective effects) 2
   • Second choice: Short-duration corticosteroids 2
   • Avoid NSAIDs 1, 2

3. For patients with diabetes or uncontrolled hypertension:

   • First choice: NSAIDs or colchicine 1
   • Avoid corticosteroids if possible 1

4. For patients with GI issues or history of ulcers:

   • First choice: Corticosteroids 1
   • Avoid NSAIDs 1

5. For severe or polyarticular attacks:

   • Consider combination therapy: colchicine + NSAIDs, or colchicine + corticosteroids 1
   • Intra-articular steroids may be combined with any other modality 1

Important Clinical Considerations

• Timing is critical: Initiate treatment within 24 hours of symptom onset for optimal results 1
• Do not interrupt ongoing urate-lowering therapy during an acute attack 1
• Prophylaxis: When initiating urate-lowering therapy, provide prophylaxis with low-dose colchicine (0.6 mg/day) or low-dose NSAIDs for 3-6 months to prevent flares 1, 5
• Monitoring: Watch for adverse effects with longer-term use, particularly with corticosteroids (dysphoria, mood disorders, elevated blood glucose, immune suppression) 1

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset 1
• Interrupting urate-lowering therapy during acute attacks 1
• Using high-dose colchicine regimens (associated with more adverse effects) 6
• Failing to consider patient comorbidities when selecting therapy 1
• Overlooking the need for prophylaxis when initiating urate-lowering therapy 1, 5

Moderate-certainty evidence shows that systemic glucocorticoids and NSAIDs are probably equally beneficial for pain relief, but NSAIDs likely result in more total adverse events 7, 6. Low-dose colchicine is as effective as high-dose but with fewer adverse events 6.