What is the recommended treatment for acute gout?

Treatment for Acute Gout

The first-line therapy for acute gout flare includes low-dose colchicine, NSAIDs, or oral glucocorticoids, with the choice based on patient-specific factors and comorbidities. 1

First-Line Treatment Options

Colchicine

• Dosing regimen: 1.2 mg (two tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Maximum recommended dose: 1.8 mg over a one-hour period
• Most effective when started within 24 hours of symptom onset
• Advantages: Rapid onset of action, can be used in patients with renal impairment (with dose adjustment)
• Common adverse effects: Gastrointestinal symptoms (diarrhea, nausea, vomiting)

NSAIDs

• Recommended regimens:
  • Naproxen 500 mg twice daily
  • Indomethacin 50 mg three times daily
  • Ibuprofen 800 mg three times daily 1
• Most effective when initiated early in the course of an attack
• Contraindicated in patients with peptic ulcer disease, severe renal impairment, uncontrolled hypertension, or heart failure

Glucocorticoids

• Oral regimen: Prednisone 30-35 mg/day for 3-5 days 1
• Intra-articular injection: Highly effective for monoarticular gout, especially in large joints
• Provides immediate reduction of painful intra-articular hypertension and pain relief within 48 hours
• Good option for patients with contraindications to NSAIDs or colchicine

Treatment Selection Algorithm

1. For patients with no contraindications:

   • Choose any of the three first-line options based on previous response and preference
   • Consider colchicine if within 24 hours of symptom onset

2. For patients with renal impairment:

   • Mild to moderate impairment: Adjust colchicine dose according to creatinine clearance
   • Severe impairment (CrCl <30 mL/min): Use reduced-dose colchicine (0.3 mg/day) or glucocorticoids
   • Dialysis patients: Single dose of 0.6 mg colchicine, not to be repeated more than once every two weeks 2

3. For patients with gastrointestinal risk factors:

   • Avoid NSAIDs
   • Use colchicine with caution due to GI side effects
   • Glucocorticoids are preferred option

4. For patients with cardiovascular disease:

   • Avoid NSAIDs
   • Use colchicine with caution in patients on certain cardiovascular medications
   • Glucocorticoids are often preferred

5. For monoarticular gout in large joints:

   • Consider intra-articular glucocorticoid injection 1

Adjunctive Measures

• Topical ice application for additional relief 1
• Rest of the affected joint
• Adequate hydration
• Avoid alcohol and purine-rich foods during acute attacks

Special Considerations

Dose Modifications for Drug Interactions

• Reduce colchicine dose when co-administered with CYP3A4 and/or P-glycoprotein inhibitors 2
• For patients on strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole):
  • Acute gout treatment: 0.6 mg (1 tablet) × 1 dose, followed by 0.3 mg (1/2 tablet) 1 hour later
  • Do not repeat treatment for at least 3 days 2

Hepatic Impairment

• Mild to moderate impairment: No dose adjustment needed for NSAIDs or colchicine, but monitor closely
• Severe impairment: Consider glucocorticoids or reduced-dose colchicine; if using NSAIDs, do not repeat treatment more than once every two weeks 2

Common Pitfalls to Avoid

1. Delaying treatment of acute flares (should initiate within 24 hours of symptom onset)
2. Interrupting urate-lowering therapy during acute attacks
3. Using high-dose colchicine regimens (associated with increased toxicity)
4. Overlooking renal function when prescribing NSAIDs or colchicine
5. Failing to consider drug interactions, especially with colchicine

Remember that the goal of acute gout treatment is rapid relief of pain and inflammation. Starting treatment early is crucial for optimal outcomes and minimizing joint damage.