What is the recommended treatment for acute gout in the emergency department?

Treatment for Acute Gout in the Emergency Department

The recommended first-line treatment for acute gout in the emergency department is low-dose colchicine (1.2 mg initially followed by 0.6 mg one hour later) if started within 36 hours of symptom onset, or oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days) if presenting later or if colchicine is contraindicated. 1

First-Line Treatment Options

Colchicine

• Dosing: 1.2 mg initially followed by 0.6 mg one hour later (total 1.8 mg over one hour) 1, 2
• Timing: Most effective when started within 12-36 hours of symptom onset 1
• Advantages: Low-dose regimen has comparable efficacy to high-dose with significantly fewer adverse effects (23% vs 77% diarrhea) 3
• Contraindications:
  • Severe renal impairment
  • Concomitant use of strong CYP3A4/P-glycoprotein inhibitors
  • Patients receiving clarithromycin, cyclosporin, ketoconazole, or ritonavir 1, 2

NSAIDs

• Dosing: Naproxen 500 mg twice daily for 5 days 1
• Contraindications:
  • Renal impairment
  • Peptic ulcer disease
  • Uncontrolled hypertension
  • Use with caution in patients with diabetes or ongoing infection 1

Oral Corticosteroids

• Dosing: Prednisolone/prednisone 30-35 mg daily for 3-5 days 1
• Evidence: Multiple studies have shown comparable efficacy to NSAIDs with potentially fewer gastrointestinal side effects 3
• Advantages: Particularly useful when colchicine or NSAIDs are contraindicated 1
• Key study: A randomized trial of 416 patients found no significant differences in pain outcomes between prednisolone and indomethacin, but fewer gastrointestinal adverse events with prednisolone 3

Special Considerations

Renal Impairment

• Mild to moderate impairment: No dose adjustment needed for NSAIDs or corticosteroids, but monitor closely 2
• Severe impairment (CrCl <30 mL/min):
  • Avoid NSAIDs
  • Colchicine: If used, do not repeat treatment course more than once every two weeks 2
  • Corticosteroids become preferred option 1
• Dialysis patients: If colchicine is used, reduce to 0.6 mg as a single dose, do not repeat more than once every two weeks 2

Hepatic Impairment

• Mild to moderate impairment: No dose adjustment needed but monitor closely 2
• Severe impairment:
  • Colchicine: Do not repeat treatment more than once every two weeks
  • Consider dose reduction for corticosteroids 2

Alternative Approaches

Intra-articular Corticosteroids

• Consider for involvement of only 1-2 joints, especially when systemic treatments are contraindicated 1

Adjunctive Measures

• Topical ice application as an adjunct to pharmacologic therapy 1
• Rest of the affected joint 4

Common Pitfalls in Emergency Department Management

1. Delayed treatment: The most important determinant of therapeutic success is how soon therapy is initiated 4
2. Inadequate diagnosis: Arthrocentesis is performed in only 8-25% of cases, with most diagnoses being clinical rather than crystal-proven 5, 6
3. Inappropriate medication use: Studies show that anti-inflammatory drugs are not given during more than 50% of ED visits for acute gout 5
4. Failure to consider renal function: 73% of hospitalized patients with acute gout have renal impairment, yet colchicine and NSAIDs are frequently used without appropriate dose adjustments 6
5. Unnecessary combination therapy: Used in over 50% of hospitalized patients despite lack of evidence supporting such combinations 6

Treatment Algorithm

1. Assess for contraindications:

   • Check renal function, hepatic function, and medication interactions
   • Review history of peptic ulcer disease or GI bleeding

2. Select appropriate therapy:

   • If symptom onset <36 hours and no contraindications: Low-dose colchicine
   • If symptom onset >36 hours or colchicine contraindicated: Oral corticosteroids
   • If single/few joints affected and no systemic therapy possible: Consider intra-articular injection

3. Provide appropriate follow-up instructions:

   • Continue medication for prescribed duration
   • Consider prophylaxis when initiating urate-lowering therapy
   • Dietary and lifestyle modifications (limit purine-rich foods, alcohol, high-fructose corn syrup)

By following this evidence-based approach to acute gout management in the emergency department, clinicians can effectively control symptoms while minimizing adverse effects and preventing recurrence.