What is the recommended treatment for gouty arthritis?

Treatment for Gouty Arthritis

The first-line treatment for acute gouty arthritis is low-dose colchicine (1.2 mg initially followed by 0.6 mg one hour later) or NSAIDs such as indomethacin (50 mg three times daily until pain is tolerable), with treatment initiated as soon as possible after symptom onset. 1, 2

Acute Gout Management

First-Line Options

• Low-dose colchicine: 1.2 mg initially followed by 0.6 mg one hour later (total 1.8 mg)

  • Should be started within 36 hours of symptom onset
  • Better safety profile than high-dose regimens (23% vs 77% diarrhea)
  • Contraindicated in severe renal impairment and with certain medications (clarithromycin, cyclosporin, ketoconazole, ritonavir)

• NSAIDs:

  • Indomethacin: 50 mg three times daily until pain is tolerable, then rapidly reduce dose 2
  • Naproxen: 500 mg twice daily for 5 days 1
  • Avoid in patients with renal impairment, peptic ulcer disease, or uncontrolled hypertension
  • Use with caution in patients with diabetes or ongoing infection

Alternative Options

• Oral corticosteroids: Prednisolone 30-35 mg daily for 3-5 days 1

  • Preferred for patients with renal impairment
  • Potentially fewer gastrointestinal side effects than colchicine or NSAIDs

• Intra-articular corticosteroid injection: For involvement of 1-2 joints 1

  • Especially useful when NSAIDs and systemic steroids are contraindicated

• IL-1 inhibitors (anakinra or canakinumab): For refractory cases 1

Non-Pharmacological Approaches

• Topical ice application
• Rest of the affected joint
• Adequate hydration

Key Considerations for Treatment Selection

Renal Function

• Normal renal function: Any first-line option (colchicine or NSAIDs)
• Moderate renal impairment: Reduced dose of colchicine; avoid NSAIDs
• Severe renal impairment (CrCl <30 mL/min): Corticosteroids preferred; avoid colchicine and NSAIDs

Timing of Treatment

• Early intervention is crucial for therapeutic success
• Treatment should begin within 36 hours of symptom onset for colchicine
• The sooner NSAIDs are initiated, the more effective they will be 3

Long-Term Management

Urate-Lowering Therapy (ULT)

• First-line: Allopurinol starting at 100 mg daily (lower in renal impairment)
  • Gradually titrate to target serum urate <6 mg/dL
• Alternatives: Febuxostat (caution with cardiovascular risk), probenecid, sulphinpyrazone
• Refractory cases: Pegloticase for frequent flares or nonresolving tophi despite other ULT

Prophylaxis When Starting ULT

• Low-dose colchicine or NSAIDs for at least 8 weeks
• Continue for 3-6 months after achieving target uric acid levels

Lifestyle Modifications

• Limit purine-rich foods, alcohol, and high-fructose corn syrup beverages
• Increase consumption of low-fat dairy products
• Maintain adequate hydration (at least 2 liters daily)
• Regular, moderate physical activity

Common Pitfalls to Avoid

• Delayed treatment initiation
• Inadequate diagnosis
• Inappropriate medication selection based on comorbidities
• Failure to consider renal function when dosing medications
• Unnecessary combination therapy
• Not providing prophylaxis when initiating ULT

The treatment approach should be guided by the patient's comorbidities, particularly renal function, and the timing of intervention is critical for successful management of acute gouty arthritis.