What is the recommended treatment for acute new gout?

Acute Treatment for New Gout

First-line treatment for acute gout includes NSAIDs, low-dose colchicine, or glucocorticoids, with the specific choice based on patient comorbidities and contraindications. 1

First-Line Treatment Options

1. Colchicine

• Dosing regimen: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg) 1
• Must be started within 36 hours of symptom onset for maximum effectiveness
• Low-dose regimen strongly recommended over high-dose due to better safety profile
• In patients with cardiovascular disease: Colchicine is considered safe and may potentially reduce the risk of myocardial infarction 2
• Dose adjustments:
  • For patients with renal impairment: No adjustment needed for mild to moderate impairment, but monitor closely 3
  • For severe renal impairment: Treatment course should not be repeated more than once every two weeks 3
  • For patients on certain medications (e.g., CYP3A4 inhibitors): Reduced dosing required 3

2. NSAIDs

• Effective for pain and inflammation control in acute gout 1, 4
• Onset of pain relief can begin within 1 hour for standard NSAIDs and within 30 minutes for naproxen sodium 4
• Caution: Should be avoided in patients with gastrointestinal, cardiovascular, or renal issues 1
• Contraindication: Should be avoided in patients with cardiovascular disease or heart failure 2

3. Glucocorticoids

• Particularly useful when oral medications cannot be taken 1
• For 1-2 joint involvement, intra-articular injections are effective 1
• Short durations of low-dose oral glucocorticoids may be safe even in patients with cardiovascular disease 2

Treatment Algorithm Based on Patient Factors

For Patients Without Comorbidities

1. First choice: NSAIDs (e.g., naproxen) for rapid pain relief 4, 5
2. Alternative: Low-dose colchicine if started within 36 hours of symptom onset 1

For Patients With Cardiovascular Disease

1. First choice: Low-dose colchicine 2
2. Alternative: Short-duration, low-dose glucocorticoids 2
3. Avoid: NSAIDs due to increased cardiovascular risk 2

For Patients With Renal Impairment

1. First choice: Glucocorticoids (oral or intra-articular) 1
2. Alternative: Adjusted-dose colchicine with careful monitoring 3
3. Avoid: NSAIDs 1

Adjunctive Therapy

• Topical ice application is recommended as an adjuvant treatment 1
• For severe acute gout (≥7/10 pain) or polyarticular involvement, combination therapy may be appropriate:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality 1

Important Considerations

• Do not discontinue urate-lowering therapy during an acute gout attack 1
• Treatment should be initiated as soon as possible, ideally within 24 hours of symptom onset 1
• The older regimen of continuing colchicine until GI side effects develop is no longer advised 1

Prevention of Recurrent Attacks

After treating the acute attack, consider:

• Weight loss if obese
• Limiting consumption of alcohol (especially beer), purine-rich foods, and high-fructose corn syrup
• Encouraging low-fat dairy products, adequate fluid intake, and regular exercise 1
• For patients with recurrent attacks (≥2 per year), tophaceous gout, or chronic kidney disease, urate-lowering therapy should be considered 1

By following this evidence-based approach to acute gout management, pain and inflammation can be effectively controlled while minimizing adverse effects based on individual patient characteristics.