What is the initial treatment for acute gout?

Initial Treatment for Acute Gout

The first-line treatment options for acute gout flare include oral colchicine, NSAIDs, or oral glucocorticoids, with the choice based on patient-specific factors and comorbidities. 1

First-Line Treatment Options

Colchicine

• Recommended 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 for treatment of gout flares is 1.8 mg over a one-hour period 2
• Most effective when started within 24 hours of symptom onset 3, 1
• Common side effects include gastrointestinal symptoms (diarrhea, nausea, vomiting)

NSAIDs

• Full dosing at FDA-approved anti-inflammatory/analgesic doses 3
• Options include:
  • Naproxen 500 mg twice daily
  • Indomethacin 50 mg three times daily
  • Ibuprofen 800 mg three times daily 1
• The most important determinant of therapeutic success is how soon NSAID therapy is initiated 4
• Caution in patients with renal impairment, peptic ulcer disease, uncontrolled hypertension, or heart failure 5

Oral Glucocorticoids

• Prednisone or prednisolone 30-35 mg daily for 3-5 days 1
• Alternative regimen: oral methylprednisolone dose pack 3
• Particularly useful when NSAIDs are contraindicated

Treatment Selection Algorithm

1. For mild/moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints:

   • Monotherapy with colchicine, NSAIDs, or oral glucocorticoids 3

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

   • Consider combination therapy with two of the following: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality 3, 1

3. For patients who cannot take oral medications (NPO):

   • Intra-articular corticosteroid injection for 1-2 affected joints 3
   • Intramuscular triamcinolone acetonide 60 mg as an alternative 3

Special Considerations

Intra-articular Corticosteroids

• Highly effective for monoarticular gout, especially in patients with large joints 1
• Provides immediate reduction of painful intra-articular hypertension and pain relief within 48 hours 1

Elderly Patients

• Use NSAIDs with caution; prefer those with short plasma half-life (diclofenac, ketoprofen) 5
• Colchicine is often poorly tolerated in the elderly 5
• Corticosteroids (intra-articular or systemic) are increasingly used for acute gout flares in elderly patients with conditions that contraindicate NSAID therapy 5

Inadequate Response to Initial Therapy

If there is inadequate response to initial therapy (defined as <20% improvement in pain within 24 hours or <50% improvement after ≥24 hours):

1. Consider alternative diagnoses 3
2. Switch to another monotherapy or add a second recommended agent 3
3. For severe refractory attacks, IL-1 inhibitors may be considered (anakinra or canakinumab) 3, 6

Important Clinical Pearls

• Treatment should be initiated within 24 hours of symptom onset for best results 3, 1
• Continue established urate-lowering therapy without interruption during an acute attack 3, 1
• Apply topical ice for additional relief 1
• Educate patients to initiate treatment upon signs and symptoms of an acute attack without needing to consult their healthcare provider for each episode 3

Common Pitfalls to Avoid

• Delaying treatment of acute flares beyond 24 hours of symptom onset 1
• Interrupting urate-lowering therapy during acute attacks 1
• Using high-dose colchicine regimens, which have significantly worse safety profiles than low-dose regimens 1
• Overlooking renal function when prescribing NSAIDs or colchicine 1

The evidence consistently supports that early intervention with any of these first-line agents leads to better outcomes, with the choice among them primarily guided by patient comorbidities and contraindications rather than significant differences in efficacy 7, 6.