What is the recommended treatment for gouty arthritis?

Treatment for Gouty Arthritis

NSAIDs, low-dose colchicine, or oral corticosteroids are all appropriate first-line options for treating acute gouty arthritis, with NSAIDs being the most convenient and well-accepted option in the absence of contraindications. 1

Acute Gout Management

First-Line Treatment Options

1. NSAIDs:

   • For acute gouty arthritis: Indomethacin 50 mg three times daily until pain is tolerable, then rapidly reduce to complete cessation 2
   • Advantages: Rapid onset of action, convenient administration
   • Best for: Young patients without significant comorbidities 1
   • Contraindications: Renal impairment, history of GI bleeding, cardiovascular disease 1, 3

2. Colchicine:

   • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg over 1 hour) 1
   • Most effective when started within 36 hours of symptom onset 1
   • Contraindications: Severe renal or hepatic impairment
   • Note: The older high-dose regimen (continuing until GI side effects develop) is no longer recommended 1

3. Corticosteroids:

   • Consider when NSAIDs and colchicine are contraindicated or for severe attacks involving multiple joints 1
   • Prednisolone 35 mg once daily for 5 days has shown equivalent efficacy to naproxen for acute gout 4
   • Particularly useful in patients with renal impairment where NSAIDs are contraindicated 3

Treatment Considerations

• Timing is crucial: Initiate treatment within 24 hours of symptom onset for best results 1
• Non-pharmacological adjuncts: Topical ice application and rest of the affected joint 5
• Special populations: In patients with chronic kidney disease (CKD), avoid NSAIDs and reduce colchicine dosage based on kidney function 3

Long-term Management

Urate-Lowering Therapy (ULT)

Indicated for patients with:

• Recurrent attacks (≥2 per year)
• Tophaceous gout
• Chronic kidney disease 1

ULT Options:

1. Allopurinol:

   • First-line option
   • Initial dose ≤100 mg/day, titrated gradually to achieve target uric acid level <6 mg/dL 1
   • Dose adjustment required in renal impairment 3

2. Febuxostat:

   • Alternative to allopurinol
   • Use with caution due to increased risk of cardiovascular events 1
   • Limited data in severe renal impairment (CrCl <30 mL/min) 3

3. Pegloticase:

   • Reserved for patients who have failed other options 1
   • Particularly for frequent attacks or persistent tophi 6

Prophylaxis During ULT Initiation

• Always provide prophylaxis when starting ULT to prevent acute flares 1
• Options include:
  • Low-dose colchicine (0.6 mg daily)
  • Low-dose NSAIDs (if not contraindicated)
  • Continue for at least 6 months 7

Lifestyle Modifications

• Limit alcohol intake, especially beer and spirits 1
• Reduce consumption of purine-rich foods and high-fructose corn syrup 1
• Maintain adequate hydration (at least 2 liters daily) 1
• Implement weight loss program if overweight/obese 1
• Encourage low-fat dairy products 1

Common Pitfalls to Avoid

1. Delaying treatment beyond 24 hours of symptom onset 1
2. Interrupting ULT during acute attacks - continue ULT even during flares 1
3. Using high-dose colchicine regimens - the modern low-dose approach is equally effective with fewer side effects 1
4. Inadequate prophylaxis when starting ULT 1
5. Using fixed-dose allopurinol without titration to target uric acid levels 1
6. Overlooking comorbidities when selecting treatment - especially renal impairment which affects medication choice and dosing 3