What is the recommended treatment for acute gout?

Treatment for Acute Gout

The first-line treatment for acute gout flares is low-dose colchicine (1.2 mg initially, followed by 0.6 mg one hour later, for a maximum dose of 1.8 mg over a one-hour period), which is as effective as higher doses but with fewer gastrointestinal side effects. 1

First-Line Treatment Options

Colchicine

• Dosing regimen: 1.2 mg (two tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Timing: Most effective when given within 12 hours of symptom onset 1
• Maximum dose: 1.8 mg over a one-hour period 2
• Contraindications:
  • Avoid in patients with severe renal impairment (eGFR < 30 ml/min) 1
  • Use with caution in moderate renal impairment (eGFR 30-60 ml/min) 1
  • Avoid with strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole) 2

NSAIDs

• Effective first-line option for acute gout 1
• Examples: naproxen, indomethacin
• Contraindications:
  • Peptic ulcer disease
  • GI bleeding history
  • Severe renal impairment
  • Uncontrolled hypertension
  • Heart failure 1

Corticosteroids

• Dosing: Prednisolone 30-35 mg daily for 3-5 days 1
• Particularly useful when NSAIDs or colchicine are contraindicated 1
• Administration options:
  • Oral
  • Intra-articular (for 1-2 affected joints)
  • Intramuscular or intravenous for severe cases 1

Special Populations

Renal Impairment

• Mild to moderate impairment: Monitor closely for adverse effects
• Severe impairment (eGFR < 30 ml/min):
  • Avoid NSAIDs and colchicine
  • Corticosteroids are preferred 1
  • If colchicine must be used, do not repeat treatment more than once every two weeks 2

Pregnancy

• Oral, intramuscular, or intra-articular glucocorticoids are recommended as the safest option 1
• NSAIDs and colchicine should be avoided 1

Elderly Patients

• Use caution with NSAIDs due to increased risk of adverse effects
• Consider lower doses of medications
• Corticosteroids may be preferred when comorbidities contraindicate NSAIDs or colchicine 1

Common Pitfalls to Avoid

1. Failure to assess renal function before initiating therapy, which can lead to colchicine toxicity 1

2. Not considering drug interactions with colchicine, particularly CYP3A4 inhibitors which can dramatically increase colchicine levels and toxicity risk 1

3. Missing early signs of colchicine toxicity such as gastrointestinal symptoms 1

4. Delaying treatment - efficacy of colchicine decreases significantly when not given within 12 hours of symptom onset 1

5. Using high-dose colchicine regimens which have similar efficacy but more side effects compared to low-dose regimens 1

Prevention of Recurrent Flares

While not directly part of acute treatment, prevention is important to mention:

• Prophylaxis is recommended when initiating urate-lowering therapy (ULT) 1
• Options include low-dose colchicine (0.5-1.0 mg daily), low-dose NSAIDs, or low-dose prednisone (7.5 mg daily) 1
• Continue prophylaxis for 3-6 months after achieving target uric acid levels 1
• Lifestyle modifications: limit purine-rich foods, alcohol (especially beer), and high-fructose corn syrup beverages 1

The treatment approach should be tailored based on the patient's comorbidities, with particular attention to renal function, gastrointestinal risk factors, and potential drug interactions to maximize efficacy while minimizing adverse effects.