What is the treatment for acute gouty (gout) arthritis?

From the Guidelines

Acute gouty arthritis is best treated with a combination of anti-inflammatory medications and lifestyle modifications, with corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine being the recommended first-line treatments, as stated by the American College of Physicians (1). For most patients, NSAIDs like indomethacin (50mg three times daily), naproxen (500mg twice daily), or ibuprofen (800mg three times daily) for 7-10 days are effective options. Colchicine is another effective option, typically given as 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve, with low-dose colchicine being recommended when using colchicine to treat acute gout (1). For patients who cannot take NSAIDs or colchicine, oral corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) can be used. Joint aspiration with corticosteroid injection may provide rapid relief for single-joint involvement. During an acute attack, patients should rest the affected joint, apply ice for 20 minutes several times daily, and maintain adequate hydration. While treating the acute attack, patients should continue any existing urate-lowering therapy as sudden changes can worsen symptoms. These medications work by reducing inflammation caused by urate crystal deposition in joints, which triggers the inflammatory cascade responsible for the intense pain, swelling, and redness characteristic of gout attacks. Treatment should begin as soon as possible after symptom onset for maximum effectiveness, as recommended by the European League Against Rheumatism (1).

Some key points to consider when treating acute gouty arthritis include:

• The importance of patient education and lifestyle modification, including weight loss if obese, reduced alcohol consumption, and a low animal purine diet (1)
• The use of urate-lowering therapy (ULT) in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout (1)
• The recommendation to start ULT at a low dose and titrate upwards until the serum uric acid target is reached (1)
• The importance of monitoring serum uric acid levels and maintaining them below 6 mg/dL (360 mmol/L) to prevent further attacks (1)

Overall, the treatment of acute gouty arthritis should be individualized based on the patient's specific needs and circumstances, with a focus on reducing inflammation, preventing further attacks, and improving quality of life.

From the FDA Drug Label

Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis

• Treatment for acute gouty arthritis: Indomethacin is effective in relieving the symptoms of acute gouty arthritis, including pain, fever, swelling, redness, and tenderness 2.
• Dosage: The dosage of indomethacin for acute gouty arthritis is not specified in the provided drug label, but it is typically administered in a dose of 50 mg three times a day until symptoms are relieved 2.

From the Research

Treatment Options for Acute Gouty Arthritis

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely prescribed drugs for the treatment of acute gout, with any of the most potent NSAIDs probably useful in controlling pain and inflammatory signs of acute gouty arthritis 3, 4, 5, 6, 7
• Colchicine is also widely used, but its toxicity, especially gastrointestinal adverse effects, is a major concern, and it should not be prescribed to patients with severe renal insufficiency or combined hepatic-renal insufficiency 3, 4, 6
• Corticosteroids are a reasonable choice for patients in whom colchicine and NSAIDs may be hazardous or for those with a history of previous intolerance to these drugs, and can be administered orally, intramuscularly, or intra-articularly 3, 4, 5, 6, 7
• IL-1 inhibitors are a new option for flare refractory to standard therapies 5

Considerations for Treatment

• The choice of drug for the treatment of acute gout will depend on the balance between its efficacy and the potential adverse effects in a particular patient, taking into account comorbidities such as chronic kidney disease and ischemic heart disease 3, 5
• Pharmacokinetic properties, such as rapid absorption and a short half-life, should be considered when selecting an NSAID for the treatment of gout, to avoid accumulation in patients with subclinical renal function impairment 3
• Patients with previous or recent gastrointestinal bleeding, those receiving anticoagulant therapy or with haemorrhage diathesis, and those with renal insufficiency are at risk of developing severe adverse effects from NSAID administration 3