What are the alternative treatments for gout if colchicine (Colchicine) is not effective?

Alternative Treatments for Gout When Colchicine Is Not Effective

When colchicine is not effective for gout treatment, NSAIDs, oral corticosteroids, intra-articular corticosteroid injections, or IL-1 inhibitors like canakinumab should be used, with the choice depending on the patient's comorbidities and contraindications. 1, 2

First-Line Alternatives to Colchicine

NSAIDs

• Recommended options include:
  • Naproxen 500 mg twice daily for 5 days
  • Indomethacin 50 mg three times daily
  • Ibuprofen 800 mg three times daily 2
• Add a proton pump inhibitor if appropriate to reduce gastrointestinal side effects 1
• Caution: Avoid in patients with severe renal impairment, cardiovascular disease, or heart failure 1, 3

Oral Corticosteroids

• Prednisone or prednisolone 30-35 mg daily for 3-5 days 1, 2
• Particularly useful when NSAIDs are contraindicated
• Studies have shown prednisolone (35 mg/day for 5 days) is equivalent to naproxen for treating gout flares 1
• Safer option for patients with cardiovascular disease or heart failure 3

Intra-Articular Corticosteroid Injection

• Highly effective for monoarticular gout 2
• Particularly useful for large joints 2
• Provides immediate reduction of painful intra-articular hypertension 1
• Triamcinolone acetonide 10 mg has been shown to provide pain relief within 48 hours 1

Advanced Options for Refractory Cases

IL-1 Inhibitors

• Canakinumab (ILARIS) is FDA-approved for gout flares when NSAIDs and colchicine are contraindicated, not tolerated, or ineffective 4
• Administered as a 150 mg subcutaneous injection 4
• Particularly effective for reducing pain intensity at 72 hours post-dose 4
• Consider in patients who have had at least three gout flares in the previous year 4

Treatment Selection Based on Comorbidities

Patients with Cardiovascular Disease

• Preferred options: Low-dose colchicine (if not already failed) or short-duration corticosteroids 3
• Avoid NSAIDs due to increased cardiovascular risk 3

Patients with Renal Impairment

• Avoid NSAIDs as they can exacerbate or cause acute kidney injury 5
• Use adjusted doses of corticosteroids
• Consider intra-articular steroid injections for monoarticular flares 2

Patients with Multiple Comorbidities

• Consider combination therapy for severe acute gout, especially when flares involve multiple joints 1
• Options include combining low-dose corticosteroids with other treatments if safe 1

Long-Term Management

Urate-Lowering Therapy (ULT)

• Should be considered if patient has:
  • Recurrent attacks (≥2 per year)
  • Tophaceous gout
  • Chronic kidney disease or urolithiasis 2
• Options include:
  • Allopurinol: First-line, start at ≤100 mg/day, gradually increase to achieve target uric acid level <6 mg/dL 2
  • Febuxostat: Alternative to allopurinol, but use with caution in patients with cardiovascular disease 2, 3
  • Probenecid: Consider as first-line in patients with cardiovascular disease 3

Prophylaxis When Starting ULT

• Always provide prophylaxis when initiating ULT to prevent flares 2, 6
• Options include low-dose colchicine (if not already failed), low-dose NSAIDs, or low-dose prednisone 6
• Continue for at least 3-6 months or until target urate level is achieved 2

Common Pitfalls to Avoid

• Delaying treatment of acute flares (initiate within 24 hours of symptom onset) 2
• Interrupting ULT during acute attacks (continue ULT during flares) 2
• Using fixed-dose allopurinol (titrate to achieve target serum uric acid levels) 2
• Overlooking renal function when prescribing NSAIDs 2
• Starting ULT during an acute attack without appropriate prophylaxis 2

By following this approach, patients with gout who do not respond to colchicine can still achieve effective symptom control and long-term management of their condition.