What is the recommended treatment for acute gout?

Treatment of Acute Gout

For acute gout flares, first-line treatment options include oral colchicine, NSAIDs, or glucocorticoids, with the specific choice depending on patient comorbidities, medication contraindications, and timing of intervention. 1

First-Line Treatment Options

Colchicine

• Dosing regimen: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg over 1 hour) 2
• Most effective when started within 12 hours of symptom onset 1
• Contraindications:
  • Severe renal impairment (eGFR < 30 ml/min) 1
  • Concomitant use of strong CYP3A4/P-glycoprotein inhibitors 2
  • Dose adjustment required for moderate renal impairment (eGFR 30-60 ml/min) 2

NSAIDs

• Preferred regimen: Short-acting NSAIDs such as naproxen 500 mg twice daily for 5 days 1
• Contraindications:
  • History of peptic ulcer disease or GI bleeding (use with PPI if necessary) 1
  • Severe renal impairment (eGFR < 30 ml/min) 1

Glucocorticoids

• Preferred regimen: Prednisone 30-35 mg daily for 3-5 days 1
• Generally safer and more cost-effective than NSAIDs 1
• Particularly beneficial for:
  • Elderly patients 1
  • Patients with renal impairment 1
  • Patients with gastrointestinal risk factors 1

Intra-articular Corticosteroids

• Particularly effective for 1-2 large affected joints 1
• Dosage based on joint size 1
• Can be used in combination with other treatments 1

Treatment Selection Algorithm

1. Assess timing of flare:

   • If within 12 hours of symptom onset → Consider colchicine as preferred option
   • If beyond 12 hours → NSAIDs or glucocorticoids may be more effective

2. Assess renal function:

   • eGFR < 30 ml/min → Avoid NSAIDs and colchicine; use glucocorticoids
   • eGFR 30-60 ml/min → Consider reduced colchicine dose or glucocorticoids; use NSAIDs with caution

3. Assess gastrointestinal risk:

   • History of peptic ulcer disease or GI bleeding → Avoid NSAIDs or use with PPI; prefer glucocorticoids or colchicine

4. Assess medication interactions:

   • Taking CYP3A4/P-gp inhibitors → Avoid or reduce colchicine dose per specific guidelines 2
   • Taking concurrent statin therapy → Monitor for colchicine toxicity

5. Assess joint involvement:

   • 1-2 large joints → Consider intra-articular corticosteroid injection
   • Polyarticular involvement → Consider combination therapy (e.g., NSAIDs + colchicine) 1

Adjunctive Measures

• Topical ice application is conditionally recommended 1
• Rest and elevation of affected joint
• Adequate hydration (at least 2 liters daily) 1

Common Pitfalls to Avoid

1. Failure to check drug interactions: Strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole) require significant colchicine dose reductions to prevent toxicity 1

2. Missing early signs of colchicine toxicity: Monitor for gastrointestinal symptoms 1

3. Inappropriate dosing: The old high-dose colchicine regimen is no longer recommended due to toxicity concerns 2

4. Continuing NSAIDs in high-risk patients: Elderly patients and those with renal impairment are at higher risk for NSAID-related adverse events 3

5. Failure to provide prophylaxis when starting urate-lowering therapy: This can trigger paradoxical flares 1

Long-Term Management Considerations

• Initiate urate-lowering therapy (ULT) such as allopurinol for patients with recurrent gout attacks (≥2 per year), tophi, joint damage, or chronic kidney disease 1
• Target serum uric acid levels below 6 mg/dL (360 μmol/L) 1
• Provide prophylaxis with colchicine 0.5-1.0 mg daily during the first 6 months of ULT to prevent paradoxical flares 1
• Recommend lifestyle modifications including weight loss for overweight patients, limiting purine-rich foods, alcohol (especially beer), and high-fructose corn syrup beverages 1

Recent evidence suggests that corticosteroids have similar efficacy to NSAIDs for pain relief in acute gout but with a more favorable safety profile, particularly regarding gastrointestinal adverse effects 3.