From the Guidelines
For a new gout attack, start with an NSAID like naproxen 500mg twice daily or indomethacin 50mg three times daily for 3-5 days, as these options are effective in reducing pain and inflammation, as recommended by the American College of Physicians 1.
Management of Acute Gout
The management of acute gout involves both pharmacologic and nonpharmacologic approaches.
- Pharmacologic therapies focus on urate-lowering strategies and anti-inflammatory drugs.
- Nonpharmacologic management focuses on dietary and lifestyle changes, including weight loss and exercise.
Treatment Options
The choice of drug(s) should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved, as recommended by the European League Against Rheumatism (EULAR) 2.
- Colchicine 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until the attack resolves, is effective if started within 24 hours of symptom onset.
- Oral prednisone 30-40mg daily for 3-5 days with a quick taper is appropriate for patients with contraindications to these medications.
- Rest the affected joint, apply ice for 20 minutes several times daily, and maintain hydration.
- Avoid alcohol and purine-rich foods during the acute attack.
Urate-Lowering Therapy
The patient should continue any existing urate-lowering therapy without interruption, as stopping can worsen the flare, as suggested by a systematic review in support of an American College of Physicians clinical practice guideline 3.
- Once the acute attack resolves, evaluate for long-term urate-lowering therapy if this is a recurrent attack or if the patient has tophi, chronic kidney disease, or frequent attacks.
- The goal of acute treatment is to reduce inflammation quickly, as gout flares result from the inflammatory response to monosodium urate crystals in the joint space, causing the characteristic severe pain, swelling, and redness.
From the FDA Drug Label
Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis The management of an acute gout attack involves the use of indomethacin to relieve symptoms such as pain, fever, swelling, redness, and tenderness 4.
- The goal is to provide symptom relief, as indomethacin does not alter the progressive course of the underlying disease.
- Indomethacin has been shown to be effective in reducing inflammation and improving symptoms in acute gouty arthritis.
From the Research
Management of Acute Gout Attack
The management of an acute gout attack involves the use of various medications to reduce pain and inflammation.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely prescribed drugs for the treatment of acute gout, as they are effective in controlling pain and inflammatory signs of acute gouty arthritis 5.
- Colchicine is also widely used, but its use is limited by toxicity, especially gastrointestinal adverse effects 5.
- Corticosteroids are a reasonable choice for patients in whom colchicine and NSAIDs may be hazardous or for those with a history of previous intolerance to these drugs 5.
- Intra-articular steroids can also be used to relieve acute arthritis urica 6.
- Systemic steroids, NSAIDs, and colchicine are also suitable for the treatment of acute gout 6.
Treatment Options
The choice of treatment for acute gout will depend on the balance between its efficacy and the potential adverse effects in a particular patient 5.
- Colchicine should not be prescribed to patients with severe renal insufficiency or combined hepatic-renal insufficiency, and doses should be halved in patients with moderate renal function impairment 5.
- NSAIDs should be used with caution in patients with comorbidities such as previous or recent gastrointestinal bleeding, those receiving anticoagulant therapy or with haemorrhage diathesis, and those with renal insufficiency 5.
- IL-1 inhibitors are a new option for flare refractory to standard therapies 7.
Long-term Management
Long-term management of gout includes lifestyle modifications and urate-lowering therapy (ULT) 8, 6, 7, 9.
- Lifestyle modifications include weight loss, avoidance of alcohol and purine-rich foods, and diuretics 8.
- ULT is indicated in patients with 2 or more gout flares/year, tophi, or radiographic evidence of gouty arthropathy 8.
- The goal of ULT is to achieve a serum uric acid level below 6 mg/dL, or less than 5 mg/dL in patients with tophi 8, 6.