What is the recommended treatment for an acute gout attack?

Treatment of Acute Gout Attack

NSAIDs, corticosteroids, or oral colchicine are the recommended first-line treatments for acute gout attacks, with therapy initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3

First-Line Treatment Options

• NSAIDs at full FDA-approved anti-inflammatory doses are effective when started promptly, with naproxen, indomethacin, and sulindac being FDA-approved options for acute gout 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is effective, especially when started within 36 hours of symptom onset, with fewer gastrointestinal side effects than higher doses 1, 4
• Oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days) are effective, particularly for patients with contraindications to NSAIDs or colchicine 1, 2
• Intra-articular corticosteroid injection is highly effective for single joint involvement 1, 5

Treatment Algorithm Based on Joint Involvement and Pain Severity

For Mild to Moderate Pain with Limited Joint Involvement:

• Choose one of the following monotherapy options:
  • NSAIDs at full anti-inflammatory doses (e.g., naproxen, indomethacin, sulindac) 1
  • Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) 4
  • Oral prednisone (0.5 mg/kg per day for 5-10 days) 1
  • Intra-articular corticosteroid injection for single joint involvement 1

For Severe Pain or Polyarticular Involvement:

• Combination therapy is appropriate with effective combinations including:
  • Colchicine plus NSAIDs 1
  • Oral corticosteroids plus colchicine 1
  • Intra-articular steroids with any other modality 1

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, 3
• Educate patients to initiate treatment upon first signs of an acute attack 5
• Apply topical ice as an adjunctive measure during acute attacks 3

Medication-Specific Considerations

NSAIDs:

• Use at full FDA-approved anti-inflammatory doses 1
• Continue until the gouty attack has completely resolved 1
• Avoid in patients with heart failure, peptic ulcer disease, or significant renal disease 3, 6

Colchicine:

• Low-dose regimen (1.2 mg followed by 0.6 mg one hour later) is as effective as higher doses with fewer gastrointestinal adverse effects 4, 7
• Adjust dose in patients with renal impairment or taking CYP3A4 inhibitors 4
• Maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period 4

Corticosteroids:

• Oral prednisone 0.5 mg/kg per day for 5-10 days at full dose, or 2-5 days at full dose followed by 7-10 day taper 1, 2
• Intra-articular injection dose varies depending on joint size 1
• Intramuscular triamcinolone acetonide 60 mg is an option 1

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1, 2
• High-dose colchicine regimens cause significant gastrointestinal side effects, while low-dose regimens are equally effective with fewer adverse events 4, 7
• Discontinuing urate-lowering therapy during acute attacks can worsen outcomes 1, 3
• NSAIDs have higher risk of gastrointestinal side effects compared to corticosteroids 6
• Colchicine has significant drug interactions, particularly with strong CYP3A4 inhibitors, which can lead to serious toxicity 4

Special Considerations

• For patients with renal impairment, corticosteroids are generally safer than NSAIDs or colchicine 2, 6
• For patients with diabetes, NSAIDs or colchicine may be preferred over corticosteroids 2
• For patients with gastrointestinal risk factors, corticosteroids or low-dose colchicine are preferred over NSAIDs 2, 6