What is the recommended treatment for acute gout?

Treatment for Acute Gout

First-line treatment for acute gout includes NSAIDs, oral colchicine, or corticosteroids, which should be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2

First-Line Treatment Options

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the gouty attack has completely resolved 1
• FDA-approved NSAIDs for acute gout include naproxen (500mg twice daily), indomethacin, and sulindac 1, 3
• Contraindicated in patients with renal disease, heart failure, or cirrhosis 1, 4
• Associated with gastrointestinal toxicity, including risk of bleeding, ulceration, and perforation 4, 5

Colchicine

• Most effective when started within 36 hours of symptom onset 6, 2
• Recommended low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over a one-hour period) 1, 7
• Low-dose regimen is as effective as higher doses with fewer gastrointestinal side effects 1, 7
• Common side effects include diarrhea, nausea, vomiting, cramps, and abdominal pain 1, 4
• Contraindicated in patients with severe renal or hepatic impairment who are using potent CYP3A4 inhibitors or P-glycoprotein inhibitors 1, 7

Corticosteroids

• Considered first-line therapy in patients without contraindications due to their safety profile and low cost 1, 2
• Options include:
  • Oral: Prednisolone 30-35 mg daily for 3-5 days 1, 6
  • Intra-articular: Particularly effective for single joint involvement 6, 2
  • Intramuscular: Triamcinolone acetonide 60 mg 1
• Contraindicated in patients with systemic fungal infections 1

Treatment Selection Considerations

Patient-Specific Factors

• Renal function: Avoid NSAIDs and adjust colchicine dose in renal impairment 4, 7
• Cardiovascular disease: Consider colchicine or corticosteroids over NSAIDs 4
• Gastrointestinal risk: Avoid NSAIDs or use with gastroprotection 4
• Diabetes: Use corticosteroids with caution due to potential hyperglycemia 1

Severity of Attack

• For severe or polyarticular attacks, combination therapy may be appropriate 1, 4
• Acceptable combination approaches include:
  • Colchicine and NSAIDs
  • Oral corticosteroids and colchicine
  • Intra-articular steroids with any other modality 1

Important Principles

• Initiate treatment within 24 hours of symptom onset for best outcomes 1, 2
• Continue urate-lowering therapy (if already prescribed) during the acute attack 1, 6
• For inadequate response (defined as <20% improvement in pain score within 24 hours or <50% at ≥24 hours), consider adding a second agent 1
• Continue treatment at full dose until the gouty attack has completely resolved 1

Common Pitfalls to Avoid

• Delaying treatment initiation, which reduces effectiveness of all options 4, 2
• Using high-dose colchicine regimens, which have similar efficacy but significantly more side effects than low-dose regimens 1, 7
• Discontinuing urate-lowering therapy during acute flares 1, 2
• Failing to adjust colchicine dosing in patients with renal impairment or those taking interacting medications 4, 7
• Not considering drug interactions, particularly with colchicine 6, 7

Prophylaxis After Acute Attack

• Prophylaxis is strongly recommended when starting urate-lowering therapy 1, 2
• Options include:
  • Low-dose colchicine (0.6 mg once or twice daily) 1, 6
  • Low-dose NSAIDs 1
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1
• Continue prophylaxis 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, 6