What are the characteristics and treatment options for an acute gout attack?

Acute Gout Attack: Characteristics and Treatment

An acute gout attack is characterized by sudden onset of intense pain, erythema, and swelling typically affecting a single joint, most commonly the first metatarsophalangeal joint (podagra), and requires prompt treatment with NSAIDs, colchicine, or corticosteroids initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3

Clinical Presentation

• Acute gout presents as a sudden monoarthritis with rapid onset and intense pain, most commonly affecting the first metatarsophalangeal joint (50% of initial attacks), but can also involve the foot, ankle, knee, wrist, elbow, and other joints 4
• Pain severity is typically moderate to severe (≥7 on a 0-10 scale), with associated erythema, swelling, and tenderness 1
• Attacks can be categorized based on:
  • Duration: early (<12 hours), established (12-36 hours), or late (>36 hours) 1
  • Extent: limited (1-2 small joints), moderate (1-2 large joints), or polyarticular (≥3 large joints or ≥4 joints across multiple regions) 1
• Periarticular structures including bursae and tendons may also be affected 4

Diagnosis

• Definitive diagnosis requires identification of monosodium urate (MSU) crystals in synovial fluid, which appear needle-like and show strong negative birefringence under polarized microscopy 4, 5
• Clinical criteria from the American College of Rheumatology can be used for diagnosis when joint aspiration is not feasible 5

Treatment Approach

General Principles

• Treatment should be initiated within 24 hours of symptom onset for optimal effectiveness 1, 2, 3
• Ongoing urate-lowering therapy (ULT) should not be interrupted during an acute attack 1, 6
• Choice of therapy depends on pain severity, number of joints involved, and patient-specific contraindications 6, 3

First-Line Treatment Options

1. NSAIDs:

   • Use full FDA-approved anti-inflammatory/analgesic doses 1, 2
   • FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 1, 2
   • Continue at full dose until the attack completely resolves 1
   • Contraindicated in patients with significant renal disease, heart failure, or peptic ulcer disease 3

2. Colchicine:

   • Most effective when started within 36 hours of symptom onset 1
   • Low-dose regimen (1.2 mg followed by 0.6 mg 1 hour later) is as effective as higher doses with fewer gastrointestinal side effects 2, 3, 7
   • Requires dose adjustment in patients with renal impairment and for drug interactions 1, 3

3. 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 2
     • Prednisolone 35 mg for 5 days 2
     • Intra-articular corticosteroid injection for single joint involvement 3
   • Preferred in patients with renal impairment or contraindications to NSAIDs/colchicine 2, 3

Treatment Algorithm Based on Attack Severity

• Mild to moderate pain (≤6/10) with limited joint involvement:

  • Monotherapy with any first-line agent (NSAID, colchicine, or corticosteroid) 2, 6
  • Topical ice application as adjunctive therapy 3

• Severe pain (≥7/10) or polyarticular involvement:

  • Combination therapy is appropriate 2, 6
  • Effective combinations include:
    • Colchicine plus NSAID
    • Oral corticosteroid plus colchicine
    • Intra-articular steroids with any other modality 2, 6

Prevention of Recurrent Attacks

• Anti-inflammatory prophylaxis is recommended when initiating urate-lowering therapy 1, 6, 3
• First-line prophylactic options include low-dose colchicine or low-dose NSAIDs 6, 3
• Prophylaxis should continue for at least 6 months or until serum urate target is achieved 6, 3
• Patients should limit consumption of purine-rich foods (organ meats, shellfish), alcoholic drinks (especially beer), and beverages sweetened with high-fructose corn syrup 5

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 6, 3
• Using high-dose colchicine regimens causes significant gastrointestinal side effects without additional benefit 3
• Discontinuing urate-lowering therapy during acute flares can worsen and prolong the attack 6, 3
• Combining NSAIDs with systemic corticosteroids increases risk of gastrointestinal toxicity 6
• Failing to consider drug interactions, particularly with colchicine, can lead to serious toxicity 3