What is the initial management for acute gout?

Initial Management of Acute Gout

The first-line treatment for acute gout flares is oral colchicine, NSAIDs, or glucocorticoids, with the choice depending on patient-specific factors such as comorbidities and medication contraindications. 1

First-Line Medication Options

1. Colchicine

• Dosing regimen: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg over one hour) 1, 2
• Most effective: When started within 12 hours of symptom onset 1
• Contraindications:
  • Renal impairment (eGFR < 30 ml/min) 1
  • Concurrent use of strong CYP3A4/P-glycoprotein inhibitors 2
• Dose adjustment: Required for patients with moderate renal impairment (eGFR 30-60 ml/min) or taking interacting medications 1, 2

2. NSAIDs

• Preferred agent: Short-acting NSAIDs like naproxen 500 mg twice daily for 5 days 1
• Alternative: Indomethacin 50 mg three times daily until pain is tolerable, then rapidly taper 3
• Contraindications:
  • History of peptic ulcer disease or GI bleeding (unless used with PPI) 1
  • Significant cardiovascular disease 1
  • Renal impairment (eGFR < 30 ml/min) 1

3. Corticosteroids

• Oral regimen: Prednisone 30-35 mg daily for 3-5 days 1
• Intra-articular: Particularly effective for 1-2 large joints 1
• Intramuscular option: Compound betamethasone 7 mg as a single dose 4
• Preferred in: Elderly patients and those with comorbidities that contraindicate NSAIDs or colchicine 1

Treatment Selection Algorithm

1. For patients with recent symptom onset (< 12 hours) and no contraindications:

   • Colchicine is preferred due to high efficacy when given early 1

2. For patients with normal renal function and no cardiovascular risk factors:

   • NSAIDs are a good first choice 1, 3

3. For elderly patients or those with comorbidities:

   • Corticosteroids are generally safer and more cost-effective 1

4. For severe polyarticular involvement:

   • Consider combination therapy: NSAIDs + colchicine, oral corticosteroids + colchicine, or intra-articular injections with another modality 1

5. For monoarticular gout affecting 1-2 large joints:

   • Intra-articular corticosteroid injection is particularly effective 1

Adjunctive Measures

• Topical ice: Conditionally recommended as an adjuvant treatment 1
• Rest: Immobilization of the affected joint(s) 5
• Avoid dietary triggers: During acute attacks, limit purine-rich foods (organ meats, shellfish), alcoholic beverages (especially beer), and high-fructose corn syrup beverages 1, 6

Common Pitfalls to Avoid

1. Delayed treatment: The most important determinant of therapeutic success is how soon therapy is initiated 5

2. Overlooking drug interactions: Particularly with colchicine and CYP3A4 inhibitors (clarithromycin, ketoconazole), which can lead to toxicity 1, 2

3. Failing to recognize colchicine toxicity: Monitor for early signs, particularly gastrointestinal symptoms 1

4. Not assessing renal function: Critical before prescribing colchicine or NSAIDs 1

5. Initiating urate-lowering therapy during an acute attack: This can worsen or prolong the attack; focus on treating the acute inflammation first 6, 7

After the acute attack resolves, address modifiable risk factors and consider long-term management strategies for patients with recurrent gout attacks (≥2 per year), tophi, joint damage, or chronic kidney disease 1.