What is the recommended treatment for acute gout?

Treatment of Acute Gout

For acute gout attacks, corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option, followed by NSAIDs or colchicine as alternatives based on patient-specific factors. 1

First-Line Treatment Options

Corticosteroids

• Corticosteroids are among the most effective anti-inflammatory medications available and have been shown to be as effective as NSAIDs for managing gout, with fewer adverse effects 1
• Prednisolone at a dose of 35 mg for 5 days has been successfully used to treat acute gout 1
• Administration options include oral, intra-articular (for single joint involvement), or intramuscular routes 1
• 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

• Should be used at full anti-inflammatory doses when started promptly 1, 2
• No difference in efficacy between different types of NSAIDs, including indomethacin 1
• Naproxen has been shown to decrease inflammatory changes within 24-48 hours in acute gout 3
• Contraindicated in patients with renal disease, heart failure, or cirrhosis 1, 4
• Adverse effects include dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding 1

Colchicine

• Low-dose colchicine (1.2 mg followed by 0.6 mg 1 hour later) is as effective as higher doses with fewer gastrointestinal adverse effects 1, 5
• Most effective when started within 12-24 hours of symptom onset 2, 6
• Contraindicated in patients with renal or hepatic impairment who are using potent cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors 1, 5
• Adverse effects include gastrointestinal issues (diarrhea, nausea, vomiting, cramps, pain) and occasionally headache and fatigue 1

Treatment Algorithm for Acute Gout

1. Initiate treatment within 24 hours of symptom onset for optimal outcomes 1, 6

2. For mild to moderate pain (≤6/10 on pain scale) with 1-3 small joints or 1-2 large joints:

   • Start with monotherapy 1
   • Choose based on:
     • Patient comorbidities
     • Medication contraindications
     • Prior response to therapy
     • Cost considerations

3. For severe pain or polyarticular involvement (>3 joints):

   • Consider combination therapy 1
   • Acceptable combinations include:
     • Colchicine + NSAIDs
     • Oral corticosteroids + colchicine
     • Intra-articular steroids with any other modality 1

4. If inadequate response to initial therapy:

   • Add a second agent from a different class 1
   • For colchicine, inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement at ≥24 hours 1

Important Clinical Considerations

• Do not interrupt ongoing urate-lowering therapy during an acute gout attack 1, 6
• Non-pharmacological measures such as rest and topical ice application can be helpful adjuncts 6
• Patient education is important so patients can initiate treatment promptly upon signs and symptoms of an acute attack 1

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 6
• Using high-dose colchicine regimens which cause significant gastrointestinal side effects while providing no additional benefit over low-dose regimens 1
• Failing to adjust colchicine dosing in patients with renal impairment or those taking interacting medications 6, 5
• Not considering drug interactions, particularly with colchicine, which can lead to serious toxicity 6, 5
• Discontinuing urate-lowering therapy during acute flares, which can worsen outcomes 1, 6

Prevention of Recurrent Attacks

• Anti-inflammatory prophylaxis is strongly recommended when starting urate-lowering therapy 1, 2
• Options include low-dose colchicine (0.6 mg daily or twice daily), low-dose NSAIDs, or low-dose prednisone (<10 mg/day) 1, 2
• Prophylaxis should continue for at least 6 months, or 3 months after achieving target serum urate if no tophi are present, or 6 months after achieving target serum urate if tophi are present 1, 2