What is the step-by-step algorithm for treating acute gout?

Step-by-Step Algorithm for Treating Acute Gout

For acute gout attacks, initiate treatment within 24 hours with NSAIDs, corticosteroids, or low-dose colchicine as first-line monotherapy for mild-to-moderate attacks, and use combination therapy for severe polyarticular attacks. 1, 2, 3

Step 1: Initiate Treatment Immediately

• Start therapy within 24 hours of symptom onset for optimal pain relief and treatment response 1, 2, 3
• Continue any established urate-lowering therapy without interruption during the acute attack 1, 2, 3
• Educate patients to self-initiate treatment at first warning symptoms ("pill in the pocket" approach) 4

Step 2: Assess Attack Severity and Joint Involvement

For Mild-to-Moderate Pain (≤6/10 on pain scale) with 1-3 small joints or 1-2 large joints:

Use monotherapy with one of the following first-line options 1, 2:

Option A: NSAIDs (Full Anti-inflammatory Doses)

• Naproxen 500 mg twice daily 1, 2
• Indomethacin 50 mg three times daily 1, 2
• Continue for 5-10 days at full dose, then stop or taper over 7-10 days 1
• Add proton pump inhibitor for gastroprotection if indicated 1
• Avoid in patients with heart failure, peptic ulcer disease, or significant renal disease 2, 3

Option B: Corticosteroids

• Oral prednisone 0.5 mg/kg per day (or prednisolone 30-35 mg/day) for 5-10 days at full dose, then stop 1, 2, 4
• Alternative: 2-5 days at full dose followed by 7-10 day taper 1
• Preferred in patients with renal impairment or contraindications to NSAIDs/colchicine 3, 4
• Consider avoiding in diabetic patients due to glucose effects 3

Option C: Low-Dose Colchicine

• 1.2 mg followed by 0.6 mg one hour later 2, 3, 4
• Do not repeat for at least 3 days 5
• This low-dose regimen is as effective as high-dose with significantly fewer gastrointestinal side effects 2, 3, 4
• Adjust dose for renal impairment: severe impairment (CrCl <30 mL/min) requires single 0.6 mg dose, not repeated more than once every 2 weeks 5
• Adjust dose for drug interactions: reduce by 50-75% with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, protease inhibitors) 5

Option D: Intra-articular Corticosteroid Injection

• Highly effective for single joint involvement 1, 2, 3
• Dose varies by joint size 1
• Can be combined with oral agents 1

For Severe Pain (≥7/10) or Polyarticular Involvement (≥4 joints):

Use combination therapy 1, 2, 4:

• Colchicine plus NSAIDs 1, 4
• Oral corticosteroids plus colchicine 1, 4
• Intra-articular steroids plus any oral agent 1, 4
• Do NOT combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1

Step 3: Add Adjunctive Non-Pharmacologic Measures

• Apply topical ice to affected joint(s) 2, 3
• Rest the inflamed joint 6

Step 4: Assess Response to Treatment

Define inadequate response as 2, 4:

• <20% improvement in pain within 24 hours, OR
• <50% improvement after 24 hours of therapy

If inadequate response occurs:

• Switch to another monotherapy agent 4
• Add a second recommended agent 1, 4
• For severe refractory attacks, consider IL-1 inhibitors (anakinra or canakinumab) as off-label options 4

Step 5: Special Population Considerations

Renal Impairment:

• Corticosteroids are safest option 3, 4
• Colchicine requires dose adjustment:
  • Mild-moderate impairment (CrCl 30-80 mL/min): monitor closely, no dose adjustment needed 5
  • Severe impairment (CrCl <30 mL/min): 0.6 mg single dose for treatment, not repeated more than once every 2 weeks 5
  • Dialysis patients: 0.6 mg single dose, not repeated more than once every 2 weeks 5
• Avoid NSAIDs in significant renal disease 2, 3

Hepatic Impairment:

• Mild-moderate impairment: monitor closely, no dose adjustment needed 5
• Severe impairment: colchicine treatment course should not be repeated more than once every 2 weeks 5

NPO (Nil Per Os) Patients:

• For 1-2 affected joints: intra-articular corticosteroid injection 4
• For multiple joints: IV/IM methylprednisolone 0.5-2.0 mg/kg or subcutaneous ACTH 25-40 IU 4

Patients with Gastrointestinal Risk Factors:

• Prefer corticosteroids or low-dose colchicine over NSAIDs 3

Diabetic Patients:

• Consider NSAIDs or colchicine over corticosteroids to avoid glucose elevation 3

Critical Pitfalls to Avoid

• Never use high-dose colchicine regimens (>1.8 mg total initial dose) - they cause severe gastrointestinal toxicity without additional benefit 2, 3, 4
• Never stop urate-lowering therapy during an acute attack - this worsens outcomes 1, 2, 3
• Never treat acute gout with colchicine in patients already on prophylactic colchicine plus strong CYP3A4 inhibitors 5
• Never delay treatment beyond 24 hours - effectiveness decreases significantly 2, 3
• Never use colchicine for acute treatment in patients on prophylactic colchicine without extending the dosing interval to at least 3 days 5