What is the recommended treatment for an acute episode of gout?

Treatment of Acute Gout Episode

For an acute gout attack, initiate treatment within 24 hours with corticosteroids as first-line therapy (prednisolone 35 mg daily for 5 days or prednisone 0.5 mg/kg daily for 5-10 days), NSAIDs at full anti-inflammatory doses, or low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), with choice guided by contraindications and severity of presentation. 1, 2, 3

First-Line Treatment Options

All three medication classes are equally effective for acute gout, but selection depends on patient-specific factors 1:

Corticosteroids (Preferred First-Line)

• Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and low-cost 1
• Prednisolone 35 mg daily for 5 days has been successfully used 1, 3
• Alternative dosing: prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 3
• Intra-articular corticosteroid injection is highly effective for single joint involvement 3, 4
• Preferred in patients with renal impairment, heart failure, cirrhosis, or gastrointestinal risk factors 1, 3
• Avoid in patients with diabetes (prefer NSAIDs or colchicine), systemic fungal infections, or poorly controlled hyperglycemia 1, 3

NSAIDs

• Use at full FDA-approved anti-inflammatory/analgesic doses 2, 3
• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 2, 3
• Indomethacin has no evidence of superior efficacy compared to other NSAIDs 1, 3
• Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 4
• Most important determinant of success is early initiation, not which specific NSAID is chosen 5

Colchicine

• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later, maximum 1.8 mg over one hour) is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 2, 6
• Most effective when started within 36 hours of symptom onset 2
• Dose adjustments required with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, ritonavir, ketoconazole, etc.) 6
• In patients on strong CYP3A4 inhibitors: reduce to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, not to be repeated for at least 3 days 6
• Requires dose reduction in severe renal impairment (CrCl <30 mL/min): single 0.6 mg dose, not repeated more than once every two weeks 6

Treatment Algorithm Based on Severity

Mild to Moderate Pain (≤6/10) with Limited Joint Involvement

• Monotherapy with any first-line agent is appropriate 3
• Choose based on contraindications and patient comorbidities 3

Severe Pain (≥7/10) or Polyarticular Involvement

• Combination therapy is appropriate and more effective 3, 4
• Effective combinations include:
  • Colchicine plus NSAIDs 3, 4
  • Oral corticosteroids plus colchicine 3, 4
  • Intra-articular steroids with any other modality 3, 4
• Avoid combining NSAIDs with systemic corticosteroids due to increased gastrointestinal toxicity risk 2

Critical Timing and Management Principles

• Treatment must be initiated within 24 hours of symptom onset for optimal effectiveness 2, 3, 4
• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 4
• Continue established urate-lowering therapy without interruption during an acute attack 2, 3, 4
• Discontinuing urate-lowering therapy during acute flares can worsen and prolong the attack 2, 4
• Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 4

Special Populations

Renal Impairment

• Corticosteroids are safer than NSAIDs or colchicine 3, 4
• For severe renal impairment (CrCl <30 mL/min) or dialysis patients: colchicine dose is 0.6 mg × 1, not repeated more than once every two weeks 6
• NSAIDs are contraindicated in significant renal disease 1, 4

Hepatic Impairment

• For mild to moderate hepatic impairment: no dose adjustment needed but monitor closely 6
• For severe hepatic impairment: colchicine treatment course should not be repeated more than once every two weeks 6

Patients Unable to Take Oral Medications (NPO)

• Intra-articular corticosteroid injection for 1-2 affected joints 4
• Intravenous/intramuscular methylprednisolone (0.5-2.0 mg/kg) for multiple joint involvement 4

Management of Inadequate Response

• Consider inadequate response if <20% improvement in pain within 24 hours or <50% improvement after 24 hours 4
• Switch to another monotherapy or add a second recommended agent 4
• For severe refractory attacks, IL-1 inhibitors (anakinra or canakinumab) may be considered, though off-label 4

Common Pitfalls and Caveats

• High-dose colchicine regimens cause significant gastrointestinal side effects without additional benefit 2, 4
• Drug interactions with colchicine must be carefully considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors 2, 4, 6
• Treatment of gout flares with colchicine is not recommended in patients already receiving prophylactic colchicine and CYP3A4 inhibitors 6
• If treating a flare in a patient on prophylactic colchicine: maximum dose is 1.2 mg followed by 0.6 mg one hour later, then wait 12 hours before resuming prophylactic dose 6
• Topical ice application can be used as an adjunctive measure during acute attacks 4