What is the treatment and duration for an acute arthritis attack?

Treatment and Duration for Acute Arthritis Attack

For an acute gout attack, initiate treatment within 24 hours using NSAIDs, colchicine (if within 36 hours of onset), or corticosteroids at full dose, continuing until complete resolution of symptoms—typically 5-14 days depending on the agent and severity. 1

Timing is Critical

• Start pharmacologic therapy within 24 hours of symptom onset for optimal outcomes 1
• Colchicine is only effective if started within 36 hours of symptom onset 1, 2
• Early treatment leads to better patient-reported outcomes and faster resolution 1

First-Line Treatment Options

The choice depends on severity (pain scale 0-10), number of joints involved, and patient comorbidities 1:

NSAIDs (Preferred for Most Patients)

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1
• FDA-approved options include:
  • Indomethacin 50 mg three times daily until pain is tolerable, then rapidly reduce 3
  • Naproxen at full anti-inflammatory dose 1
  • Sulindac at approved dose 1
• Duration: Continue at full dose until complete resolution, typically 7-14 days for acute painful shoulder conditions, 2-4 hours for pain relief in gout with complete resolution in 3-5 days 3
• Do not taper unless multiple comorbidities or renal/hepatic impairment present 1

Colchicine (If Started ≤36 Hours)

• Loading dose: 1.2 mg, followed by 0.6 mg one hour later 1, 2
• Then continue 0.6 mg once or twice daily starting 12 hours after loading dose until attack resolves 1, 2
• Duration: Continue until complete resolution of the acute attack 1
• Critical caveat: If patient is already on prophylactic colchicine, choose a different therapy (NSAID or corticosteroid) 1
• Dose adjustment required for moderate-to-severe chronic kidney disease and drug interactions with CYP3A4/P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine) 1
• For dialysis patients: single 0.6 mg dose, do not repeat for 2 weeks 2

Corticosteroids (Alternative or When NSAIDs/Colchicine Contraindicated)

• Oral prednisone 0.5 mg/kg/day 1, 2
• Duration options:
  • 5-10 days at full dose then stop, OR 1, 2
  • 2-5 days at full dose then taper over 7-10 days then stop 1, 2
• Intra-articular injection: Dose varies by joint size (appropriate for 1-2 joint involvement) 1, 2
• Intramuscular triamcinolone acetonide 60 mg followed by oral prednisone 1

Treatment Based on Attack Severity

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

• Monotherapy with any of the above options 1
• No preference for one agent over another; base choice on comorbidities and prior response 1

Severe or Polyarticular (≥4 Joints, Multiple Regions)

• Combination therapy with two agents at full doses (or full dose of one + prophylactic dose of other) 1
• Recommended combinations:
  • Colchicine + NSAIDs 1
  • Oral corticosteroids + colchicine 1
  • Intra-articular steroids + any other modality 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

NPO (Nothing By Mouth) Patients

• Intra-articular corticosteroid injection for 1-2 joints (dose depends on joint size) 1
• IV or IM methylprednisolone 0.5-2.0 mg/kg 1
• Subcutaneous ACTH 25-40 IU with repeat doses as needed 1

Inadequate Response to Initial Therapy

Define inadequate response as: <20% pain improvement within 24 hours OR <50% improvement ≥24 hours after starting treatment 1

If inadequate response:

• Consider alternative diagnoses 1
• Switch to another monotherapy from the options above 1
• Add a second recommended agent 1

Critical Management Principles

• Do NOT stop urate-lowering therapy (ULT) during an acute attack—continue without interruption 1
• Patient education: Instruct patients to self-initiate treatment at first sign of attack without waiting for physician consultation 1
• Prophylaxis: When initiating ULT, start prophylaxis (colchicine 0.6 mg once or twice daily, or low-dose NSAID) for at least 6 months or 3 months after achieving target uric acid with no tophi 1, 2

Common Pitfalls to Avoid

• Starting colchicine >36 hours after symptom onset (ineffective) 1, 2
• Giving additional colchicine to patients already on prophylactic colchicine 1
• Stopping ULT during acute attack (worsens disease control) 1
• Tapering NSAIDs before complete resolution (leads to rebound) 1
• Using high-dose colchicine regimens (outdated, causes excessive GI toxicity) 1
• Combining NSAIDs with systemic corticosteroids (GI toxicity risk) 1