What is the recommended management for an acute gout attack?

Management of Acute Gout Attack

Corticosteroids, NSAIDs, or colchicine should be used as first-line therapy for acute gout attacks, with treatment initiated within 24 hours of symptom onset for optimal outcomes. 1, 2

First-Line Treatment Options

Corticosteroids

• Considered first-line therapy in patients without contraindications due to safety profile and low cost 1
• Prednisolone 35 mg for 5 days has been successfully used to treat acute gout 1
• Alternative dosing: 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, 3
• Contraindicated in patients with systemic fungal infections 1
• Potential adverse effects with long-term use include dysphoria, mood disorders, elevated blood glucose, immune suppression, and fluid retention 1

NSAIDs

• Use full FDA-approved anti-inflammatory/analgesic doses 1
• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 1
• No evidence that indomethacin is more efficacious than other NSAIDs 1
• Contraindicated in patients with renal disease, heart failure, or cirrhosis 1
• Common adverse effects include dyspepsia and potential gastrointestinal complications 1

Colchicine

• Low-dose colchicine regimen (1.2 mg followed by 0.6 mg 1 hour later) is as effective as higher doses with fewer gastrointestinal adverse effects 1
• If patient is already on prophylactic colchicine, use alternative therapy (NSAID or corticosteroid) 1
• Contraindicated in patients with renal or hepatic impairment who are using potent cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors 1
• More expensive than NSAIDs or corticosteroids, even with generic formulation 1

Treatment Algorithm Based on Joint Involvement and Pain Severity

Mild to Moderate Pain (≤6/10) with Limited Joint Involvement

• Monotherapy with any of the first-line agents is appropriate 1
• For 1-3 small joints or 1-2 large joints, use single agent therapy 1

Severe Pain or Polyarticular Involvement

• Combination therapy is appropriate for severe pain or polyarticular attacks 1, 3
• Effective combinations include:
  • Colchicine plus NSAIDs 3
  • Oral corticosteroids plus colchicine 3
  • Intra-articular steroids with any other modality 3

Important Principles

• Initiate treatment within 24 hours of symptom onset for best results 1, 2
• Continue established urate-lowering therapy without interruption during an acute attack 1, 2
• Educate patients to initiate treatment upon first signs of an acute attack 1
• For patients with a single or infrequent gout attacks (<2 per year), long-term urate-lowering therapy is not recommended 1

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 2
• Stopping urate-lowering therapy during an acute attack can worsen and prolong symptoms 2
• Using high-dose colchicine regimens increases risk of adverse effects without improving efficacy 1
• Combining NSAIDs with systemic corticosteroids increases gastrointestinal toxicity risk 2

Special Considerations

• For patients with renal impairment: corticosteroids are generally safer than NSAIDs or colchicine 1
• For patients with diabetes: NSAIDs or colchicine may be preferred over corticosteroids 1
• For patients with gastrointestinal risk factors: corticosteroids or low-dose colchicine are preferred over NSAIDs 1