What are the treatment options for acute gout?

Treatment of Acute Gout

For acute gout, initiate treatment within 24 hours of symptom onset with NSAIDs, oral colchicine, or corticosteroids as first-line monotherapy, selecting based on patient comorbidities and contraindications. 1, 2

First-Line Treatment Options

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the acute attack completely resolves 3, 1
• FDA-approved NSAIDs include naproxen (500mg twice daily), indomethacin, and sulindac 1
• No single NSAID is superior to another; the key is early initiation rather than agent selection 3, 4
• Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 5

Colchicine

• Most effective when started within 36 hours of symptom onset 3, 1
• Recommended low-dose regimen: 1.2 mg loading dose followed by 0.6 mg one hour later (total 1.8 mg over one hour) 1, 2
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 2, 5
• After the loading dose, continue 0.6 mg once or twice daily (prophylactic dosing) 12 hours later until the attack resolves 3
• Requires dose reduction in moderate to severe chronic kidney disease and with strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin) 3, 5

Corticosteroids

• Considered first-line therapy due to safety profile and low cost, particularly when NSAIDs and colchicine are contraindicated 1, 2
• Oral 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 2
• Alternative: prednisolone 35 mg daily for 5 days 2
• Intra-articular corticosteroid injection is highly effective for single joint involvement 2, 5
• For NPO patients with polyarticular involvement: intravenous/intramuscular methylprednisolone (0.5-2.0 mg/kg) 5
• Use with caution in diabetic patients due to hyperglycemia risk 1

Treatment Selection Algorithm Based on Comorbidities

Renal Impairment

• Corticosteroids are the safest option 2, 5
• Avoid NSAIDs 1
• Reduce colchicine dose or avoid entirely depending on severity 3

Cardiovascular Disease

• Prefer colchicine or corticosteroids over NSAIDs 1

Gastrointestinal Risk Factors

• Prefer corticosteroids or low-dose colchicine over NSAIDs 2
• If NSAIDs are used, add gastroprotection 1

Diabetes

• Prefer NSAIDs or colchicine over corticosteroids 2

Combination Therapy for Severe Disease

• For severe pain (≥7/10) or polyarticular involvement, use combination therapy 2, 5
• Effective combinations include:
  • Colchicine plus NSAIDs 2, 5
  • Oral corticosteroids plus colchicine 2, 5
  • Intra-articular steroids with any other modality 2, 5

Critical Management Principles

• Initiate treatment within 24 hours of symptom onset for optimal outcomes 1, 2, 5
• Continue treatment at full dose until the gouty attack has completely resolved 3, 1
• Continue established urate-lowering therapy (if already prescribed) without interruption during the acute attack 1, 2, 5
• Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 5

Management of Inadequate Response

• Define inadequate response as <20% improvement in pain within 24 hours or <50% improvement after 24 hours 5
• Switch to another monotherapy or add a second recommended agent 1, 5
• For severe refractory attacks, IL-1 inhibitors (anakinra or canakinumab) may be considered, though off-label 5, 6

Prophylaxis After Acute Attack

• Strongly recommended when starting urate-lowering therapy 1, 5
• Options include low-dose colchicine (0.6 mg once or twice daily), low-dose NSAIDs with gastroprotection, or low-dose prednisone 1, 5
• 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, 5

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 5, 4
• Avoid high-dose colchicine regimens (previously used dosing of repeated doses until diarrhea) as they cause severe gastrointestinal toxicity without additional benefit 5
• Never discontinue urate-lowering therapy during acute flares 2, 5
• Inadequate duration of prophylaxis when initiating urate-lowering therapy leads to breakthrough flares and poor adherence 5
• Monitor for colchicine drug interactions, particularly with strong P-glycoprotein/CYP3A4 inhibitors, which can cause life-threatening toxicity 3, 5