What is the guideline treatment for acute gout?

Treatment of Acute Gout

Corticosteroids, NSAIDs, or low-dose colchicine are the first-line treatments for acute gout attacks and should be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2

First-Line Treatment Options

• Corticosteroids should be considered as first-line therapy in patients without contraindications due to their safety profile and cost-effectiveness 1, 2
• Oral prednisolone at 35 mg for 5 days has been successfully used to treat acute gout 1
• NSAIDs at full anti-inflammatory doses are effective when started promptly 1, 3
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is recommended and is as effective as higher doses with fewer gastrointestinal side effects 1, 4

Treatment Selection Algorithm

For mild to moderate attacks (1-2 joints):

• Choose one of the following based on patient factors 1, 5:
  • NSAIDs at full anti-inflammatory doses (e.g., naproxen) 1, 3
  • Oral corticosteroids (prednisolone 35 mg for 5 days) 1
  • Low-dose colchicine (1.2 mg followed by 0.6 mg 1 hour later) 1, 4

For severe or polyarticular attacks:

• Consider combination therapy with two of the above agents 1, 5
• Intra-articular corticosteroid injection is effective for single joint involvement 2

Medication-Specific Considerations

NSAIDs:

• Use full FDA-approved anti-inflammatory doses 1, 3
• No evidence that indomethacin is more efficacious than other NSAIDs such as naproxen or ibuprofen 1
• Contraindicated in patients with renal disease, heart failure, or cirrhosis 1, 5
• Adverse effects include dyspepsia and potential gastrointestinal bleeding 1

Corticosteroids:

• Generally safer and more cost-effective than other options 1
• Adverse effects with long-term use include mood disorders, elevated blood glucose, immune suppression 1
• Contraindicated in patients with systemic fungal infections 1

Colchicine:

• Most effective when started within 12 hours of symptom onset 2, 6
• Dose adjustment required in renal impairment 4:
  • For mild to moderate renal impairment: no dose adjustment but monitor closely
  • For severe impairment: treatment course should not be repeated more than once every two weeks
• Contraindicated in patients with renal or hepatic impairment who are using CYP3A4 inhibitors 1, 4

Important Clinical Considerations

• Do not interrupt ongoing urate-lowering therapy during an acute attack 1, 2
• Apply topical ice as an adjunctive measure during acute attacks 2
• Initiate treatment within 24 hours of symptom onset for best results 2, 6
• For patients with frequent attacks (≥2 per year), consider long-term urate-lowering therapy with allopurinol or febuxostat 7, 8
• When initiating urate-lowering therapy, provide prophylaxis with low-dose colchicine, low-dose NSAIDs, or low-dose corticosteroids for at least 6 months to prevent flares 2, 5

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 9
• Using high-dose colchicine regimens, which cause significant gastrointestinal side effects while offering no additional benefit 1, 2
• Discontinuing urate-lowering therapy during acute flares, which can worsen outcomes 1, 2
• Failing to consider contraindications: NSAIDs in renal disease or heart failure; colchicine in severe renal impairment with CYP3A4 inhibitors 1, 4
• Inadequate duration of prophylaxis when initiating urate-lowering therapy 2, 10