When should medications be initiated for acute gout attacks?

Medication Initiation for Acute Gout Attacks

Acute gouty arthritis attacks should be treated with pharmacologic therapy initiated within 24 hours of symptom onset for optimal outcomes. 1, 2

First-Line Treatment Options

• NSAIDs, oral colchicine, or corticosteroids are all appropriate first-line options for treating acute gout attacks 1
• Treatment selection should be based on:
  • Number of joints affected
  • Severity of pain
  • Patient comorbidities
  • Previous response to therapy 1, 2

Specific Medication Recommendations:

NSAIDs

• Use full FDA-approved doses until the attack completely resolves 1
• Examples include naproxen, indomethacin, and sulindac (FDA-approved for gout treatment) 1
• Avoid in patients with significant renal impairment, history of GI bleeding, or cardiovascular disease 1

Colchicine

• Most effective when started within 36 hours of symptom onset 1, 3
• Recommended dosing: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg over 1 hour) 4, 3
• Lower doses required in patients with renal impairment or taking CYP3A4 inhibitors 4
• Common side effect is gastrointestinal distress (diarrhea, vomiting) with NNH of 1 in higher dosing regimens 5

Corticosteroids

• Options include:
  • Oral prednisone (0.5 mg/kg per day for 5-10 days) 1, 6
  • Methylprednisolone dose pack 1
  • Intra-articular injections for 1-2 affected joints 1, 6
  • Intramuscular triamcinolone acetonide (60 mg) followed by oral prednisone 1

Treatment Based on Attack Severity

Mild to Moderate (1-2 joints)

• Monotherapy with any first-line agent is appropriate 1, 2

Severe Pain or Polyarticular Gout

• Consider combination therapy with full doses of two agents 1, 6
• Appropriate combinations include:
  • Colchicine plus NSAIDs 1, 6
  • Oral corticosteroids plus colchicine 1, 6
  • Intra-articular steroids with any other modality 1, 6

Special Considerations

NPO Patients

• Intra-articular corticosteroid injections for 1-2 affected joints 1
• IV/IM methylprednisolone (0.5-2.0 mg/kg) 1, 6
• Subcutaneous ACTH (25-40 IU) with repeat doses as needed 1

Patients Already on Urate-Lowering Therapy

• Continue established urate-lowering therapy without interruption during acute attacks 1, 7
• Starting allopurinol during an acute attack does not significantly prolong the duration of the attack when appropriate anti-inflammatory treatment is given 7

Monitoring Response

• Inadequate response is defined as:
  • Less than 20% improvement in pain within 24 hours, OR
  • Less than 50% improvement after 24 hours 1, 2
• If inadequate response:
  • Consider alternative diagnoses
  • Switch to another monotherapy
  • Add a second recommended agent 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 1
• Discontinuing urate-lowering therapy during acute attacks can worsen outcomes 1
• Using colchicine in high doses increases toxicity without improving efficacy 4, 5
• Failing to adjust medication doses in patients with renal impairment 4, 8
• Not providing prophylaxis when initiating urate-lowering therapy 1

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis should be initiated with or just prior to urate-lowering therapy 1, 6
• Low-dose colchicine (0.6 mg once or twice daily) is first-line 1, 6, 4
• Low-dose NSAIDs are an appropriate alternative 1
• Continue prophylaxis for at least 6 months or 3-6 months after achieving target serum urate levels 1, 6