What is the recommended management for acute gout?

Management of Acute Gout

For acute gout, initiate treatment within 24 hours of symptom onset with first-line monotherapy using NSAIDs at full anti-inflammatory doses, oral colchicine (1.2 mg followed by 0.6 mg one hour later), or corticosteroids (prednisone 0.5 mg/kg/day or equivalent), with the choice based on contraindications and comorbidities rather than superiority of one agent over another. 1, 2, 3

General Principles

• Start treatment as early as possible, ideally within 12-24 hours of symptom onset for maximum efficacy 1, 2, 3
• Continue established urate-lowering therapy without interruption during an acute attack—do not stop allopurinol or febuxostat 1, 3
• Educate patients on the "pill in the pocket" approach to self-initiate treatment at the first warning symptoms without needing to contact their provider for each attack 1, 2

First-Line Treatment Selection Algorithm

For Mild-to-Moderate Pain (≤6/10) with 1-3 Small Joints or 1-2 Large Joints

Choose monotherapy from the following options based on patient-specific contraindications 1, 3:

NSAIDs (if no renal disease, heart failure, or cirrhosis)

• Use full FDA-approved anti-inflammatory doses until complete resolution 1, 4
• FDA-approved options: naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 1, 3, 4
• Other NSAIDs at analgesic/anti-inflammatory doses are equally effective 1
• Add proton pump inhibitor if gastrointestinal risk factors present 2
• Contraindications: severe renal impairment (GFR <30 mL/min), history of GI bleeding/ulceration, heart failure 3, 4

Oral Colchicine (if started within 36 hours of onset)

• Dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 2, 3, 5
• Low-dose regimen is as effective as high-dose with significantly fewer GI side effects 2, 3
• Most effective when started within 12 hours of symptom onset 2
• Contraindications: severe renal impairment (GFR <30 mL/min), concomitant use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, ketoconazole, ritonavir, etc.) 2, 5
• Dose adjustments required for moderate renal impairment and drug interactions 5

Corticosteroids (preferred in renal impairment or cardiovascular disease)

• Oral prednisone 0.5 mg/kg/day (30-35 mg/day) for 5-10 days at full dose then stop, OR 2-5 days at full dose then taper over 7-10 days 1, 2, 3
• Intra-articular injection for monoarticular gout (dose varies by joint size) 1, 2
• Intramuscular triamcinolone acetonide 60 mg followed by oral prednisone 1
• Safer in renal impairment and cardiovascular disease compared to NSAIDs 2, 3
• Monitor for hyperglycemia in diabetics, dysphoria, mood disorders, and fluid retention 2

For Severe Pain or Polyarticular Involvement (≥4 joints)

• Combination therapy is appropriate when severe pain is present in a polyarticular attack 1, 3
• Acceptable combinations include NSAID + colchicine, or corticosteroid + colchicine 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic GI toxicity 2

Special Population Considerations

Renal Impairment

• Mild-to-moderate (GFR 30-80 mL/min): No dose adjustment needed for acute treatment, but monitor closely 5
• Severe (GFR <30 mL/min):
  • Corticosteroids are preferred 2, 3
  • Colchicine: single dose 0.6 mg, repeat no more than once every 2 weeks 5
  • NSAIDs: contraindicated 3, 4
• Dialysis patients: Colchicine 0.6 mg single dose, repeat no more than once every 2 weeks 5

Cardiovascular Disease

• Prefer oral corticosteroids or colchicine over NSAIDs due to cardiovascular risks 2, 3

Elderly Patients

• Corticosteroids may be preferred due to lower risk of serious adverse effects compared to NSAIDs 2
• Dose selection should account for decreased renal function 5

Hepatic Impairment

• Mild-to-moderate: No dose adjustment needed, but monitor closely 5
• Severe: Colchicine treatment course should be repeated no more than once every 2 weeks 5

Management of Inadequate Response

• Inadequate response defined as: <20% improvement in pain at 24 hours or <50% improvement at 48 hours 1
• Add a second appropriate agent from a different therapeutic class 3, 4
• Consider IL-1 inhibitors (canakinumab) for patients with contraindications to all conventional therapies, though not FDA-approved for gout 1

Common Pitfalls to Avoid

• Do NOT delay treatment beyond 24 hours—early initiation is more important than which agent is chosen 1, 2, 3
• Do NOT stop urate-lowering therapy during an acute attack 1, 3
• Do NOT use colchicine for acute treatment in patients already on prophylactic colchicine—choose NSAID or corticosteroid instead 1, 5
• Do NOT combine NSAIDs with systemic corticosteroids due to increased GI toxicity risk 2
• Do NOT use high-dose colchicine—the low-dose regimen (1.8 mg total) is equally effective with fewer side effects 2, 3

Adjunctive Measures

• Apply topical ice to affected joints for additional pain relief 2
• Rest the inflamed joint during the acute attack 6

Duration of Treatment

• Continue treatment at full dose until the gouty attack has completely resolved 1, 4
• Typical duration is 5-10 days for NSAIDs and corticosteroids 1