What is the management for gouty arthritis?

Management of Gouty Arthritis

Acute gouty arthritis attacks should be treated with pharmacologic therapy initiated within 24 hours of onset, and established urate-lowering therapy (ULT) should be continued without interruption during an acute attack. 1

Acute Gout Management

First-Line Options for Acute Gout Attack

• NSAIDs, oral colchicine, or corticosteroids are all appropriate first-line options for treating acute gouty arthritis 1
• Treatment should be initiated within 24 hours of symptom onset for optimal outcomes 1
• The choice of agent depends on:
  • Pain severity
  • Number of joints involved
  • Patient comorbidities
  • Medication contraindications 1

Specific Medication Options

NSAIDs

• Use full FDA/EMA-approved anti-inflammatory doses until the attack completely resolves 1
• FDA-approved NSAIDs for acute gout include:
  • Naproxen
  • Indomethacin
  • Sulindac 1, 2
• Other NSAIDs at appropriate doses are also effective 1, 3, 4
• Consider GI protection with proton pump inhibitors when indicated 1

Colchicine

• Most effective when started within 36 hours of symptom onset 1
• Recommended dosing: 1.2 mg initially, followed by 0.6 mg one hour later, then continue with prophylactic dosing (0.6 mg once or twice daily) until attack resolves 1
• Requires dose adjustment in renal impairment and with drug interactions 1, 5

Corticosteroids

• Options include:
  • Oral: Prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 1
  • Intra-articular: Dose varies depending on joint size 1
  • Intramuscular: Triamcinolone acetonide 60 mg, followed by oral prednisone 1

Combination Therapy

• Initial combination therapy is appropriate for severe attacks, particularly with multiple large joints or polyarticular involvement 1
• Acceptable combinations include:
  • Colchicine and NSAIDs
  • Oral corticosteroids and colchicine
  • Intra-articular steroids with any other modality 1
• For inadequate response to monotherapy, adding a second agent is acceptable 1
• Avoid combining NSAIDs with systemic corticosteroids due to risk of synergistic GI toxicity 1

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis is essential when initiating urate-lowering therapy (ULT) 1
• First-line prophylactic options:
  • Low-dose colchicine: 0.6 mg once or twice daily (0.5 mg outside US) 1
  • Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI when indicated 1
• Second-line option:
  • Low-dose prednisone/prednisolone (<10 mg/day) if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1

Duration of Prophylaxis

• Continue prophylaxis for at least 6 months 1
• If no tophi are detected: continue for 3 months after achieving target serum urate 1
• If tophi are present: continue for 6 months after achieving target serum urate 1

Special Considerations

Renal Impairment

• NSAIDs should be avoided in patients with CKD due to risk of acute kidney injury 5
• Colchicine requires dose reduction based on kidney function 5
• Corticosteroids may be preferred in patients with significant renal impairment 5

Ongoing Management

• Do not interrupt urate-lowering therapy (e.g., allopurinol) during an acute attack 1, 6
• When initiating allopurinol, start with a low dose (100 mg daily) and increase at weekly intervals by 100 mg until target serum urate level of 6 mg/dL or less is achieved 6
• Maintain adequate fluid intake (at least 2 liters of urine output daily) and slightly alkaline urine to prevent urate precipitation 6

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1
• Stopping urate-lowering therapy during an acute attack can worsen and prolong the attack 1
• Failing to provide prophylaxis when initiating urate-lowering therapy 1
• Using inappropriate doses of colchicine in patients with renal impairment 5
• Combining NSAIDs with systemic corticosteroids due to increased GI toxicity risk 1