What is the recommended treatment for acute gout?

Treatment of Acute Gout

For acute gout, initiate treatment within 24 hours of symptom onset with NSAIDs, colchicine, or corticosteroids as first-line monotherapy, selecting the agent based on patient-specific contraindications rather than perceived superiority of one agent over another. 1, 2, 3

First-Line Treatment Options

All three first-line agents are equally effective when started promptly—the critical factor is timing, not which drug you choose 1, 2, 3:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1, 2
• FDA-approved options include naproxen 500 mg twice daily, indomethacin, and sulindac 1, 4, 5
• Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 3
• When cardiovascular disease is present, choose colchicine or corticosteroids instead 1
• If NSAIDs must be used in patients with gastrointestinal risk, add gastroprotection 1

Colchicine

• Low-dose regimen: 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, 4
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 2, 3
• Most effective when started within 36 hours of symptom onset, ideally within 12 hours 1, 3
• Common side effects include diarrhea, nausea, vomiting, and abdominal pain 1
• Avoid high-dose colchicine regimens—they cause severe gastrointestinal toxicity without additional benefit 3
• Requires dose adjustment in renal impairment 1
• Critical drug interactions exist with strong P-glycoprotein/CYP3A4 inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole)—reduce dose to 0.6 mg × 1, then 0.3 mg one hour later, and do not repeat for 3 days 3, 4

Corticosteroids

• Considered first-line therapy due to excellent safety profile and low cost 1, 2
• Oral prednisolone 35 mg daily for 5 days is effective 2
• Alternative dosing: prednisone 30-35 mg/day for 3-5 days 3
• Intra-articular injection is highly effective for single joint involvement 3
• Preferred option in patients with renal impairment 3
• Use with caution in diabetics due to hyperglycemia risk 1
• For NPO patients with multiple joint involvement, use IV/IM methylprednisolone 0.5-2.0 mg/kg 3

Treatment Algorithm Based on Severity

Mild to Moderate Pain (Single Joint)

• Start any single first-line agent based on contraindications 1, 2, 3
• For single joint involvement, strongly consider intra-articular corticosteroid injection 3

Severe Pain (≥7/10) or Polyarticular Involvement

• Use combination therapy: 3
  • Colchicine plus NSAIDs, OR
  • Oral corticosteroids plus colchicine, OR
  • Intra-articular steroids with any other modality

Inadequate Response to Initial Therapy

• Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours 3
• Switch to another monotherapy or add a second recommended agent 1, 3
• For severe refractory attacks, IL-1 inhibitors (anakinra or canakinumab) may be considered, though off-label 3

Critical Management Principles

• Continue urate-lowering therapy (if already prescribed) during the acute attack—do not discontinue 1, 2, 3
• Continue treatment at full dose until the attack has completely resolved 1
• Topical ice application is recommended as an adjunctive measure 3
• Educate patients on "pill in the pocket" approach—self-medicate at first warning symptoms 3

Prophylaxis When Starting Urate-Lowering Therapy

• Strongly recommended when initiating urate-lowering therapy to prevent flares 1, 2, 3
• Options include low-dose colchicine (0.6 mg once or twice daily), low-dose NSAIDs with gastroprotection, or low-dose prednisone 1, 2, 3
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate (<6 mg/dL) if no tophi present, or 6 months after achieving target if tophi present 1, 2, 3
• If treating an acute flare during prophylaxis, give colchicine 1.2 mg followed by 0.6 mg one hour later, wait 12 hours, then resume prophylactic dose 4

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2, 3
• Using high-dose colchicine regimens causes unnecessary toxicity 1, 2, 3
• Stopping urate-lowering therapy during acute flares worsens long-term outcomes 1, 2, 3
• Inadequate duration of prophylaxis leads to breakthrough flares and poor medication adherence 2, 3
• Failing to screen for drug interactions with colchicine can cause fatal toxicity 3, 4