What is the treatment for gout (Gouty) arthritis?

Treatment for Gouty Arthritis

First-line treatment for acute gouty arthritis includes NSAIDs, oral colchicine, or corticosteroids, which should be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2

Acute Gout Management

General Principles

• Acute gouty arthritis attacks should be treated with pharmacologic therapy initiated within 24 hours of symptom onset 1, 2
• Established urate-lowering therapy (ULT) should be continued without interruption during an acute attack 1
• Treatment choice depends on pain severity, number of joints involved, and patient-specific contraindications 2

First-Line Treatment Options

NSAIDs

• Full FDA-approved doses of NSAIDs (e.g., naproxen, indomethacin, sulindac) until attack completely resolves 1
• Most effective when initiated early in the course of an attack 3
• Consider GI risk factors and use with proton pump inhibitor when indicated 1
• Contraindicated in patients with severe renal impairment or history of GI bleeding 4

Colchicine

• Most effective when started within 36 hours of symptom onset 1
• Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later, then prophylactic dosing (0.6 mg once or twice daily) 1
• Requires dose adjustment in renal impairment, hepatic impairment, and with drug interactions 5
• Monitor for GI side effects, which are more common with higher doses 6

Corticosteroids

• Oral: Prednisone 0.5 mg/kg per day for 5-10 days then stop, or 2-5 days at full dose followed by 7-10 day taper 1
• Intra-articular: Appropriate for involvement of 1-2 joints (dose varies by joint size) 1
• Intramuscular: Triamcinolone acetonide 60 mg followed by oral prednisone 1

Severe or Refractory Attacks

• For severe attacks (pain score ≥7/10) or polyarticular involvement, consider combination therapy 1
• Acceptable combinations include:
  • Colchicine plus NSAIDs 1
  • Oral corticosteroids plus colchicine 1
  • Intra-articular steroids with any other modality 1
• Avoid combining NSAIDs with systemic corticosteroids due to increased GI toxicity risk 2
• For inadequate response (<20% improvement in 24 hours or <50% improvement after 24 hours), consider switching to another monotherapy or adding a second agent 1

Long-Term Management

Urate-Lowering Therapy (ULT)

• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line for prevention of recurrent gout 7, 8
• Uricosuric agents (probenecid) are appropriate for patients who cannot tolerate xanthine oxidase inhibitors 9, 3
• Target serum uric acid level should be below 6.0 mg/dL (360 μmol/L) 10

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis is essential when starting ULT to prevent flares 1, 2
• First-line prophylactic options:
  • Low-dose colchicine (0.6 mg once or twice daily) 1
  • Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI when indicated 1
• Second-line: Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1
• Continue prophylaxis for at least 6 months, or 3 months after achieving target uric acid level (if no tophi), or 6 months after achieving target (if tophi present) 1

Common Pitfalls and Special Considerations

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2
• Stopping urate-lowering therapy during an acute attack can worsen and prolong the attack 1
• Failing to provide prophylaxis when initiating ULT leads to increased flare risk 2
• Dose adjustment is required for colchicine in patients with renal or hepatic impairment 5
• For NPO patients, consider intra-articular corticosteroids for 1-2 joints or IV/IM methylprednisolone (0.5-2.0 mg/kg) 1
• Lifestyle modifications should include limiting purine-rich foods (organ meats, shellfish), alcoholic beverages (especially beer), and high-fructose corn syrup 8