What is the recommended treatment for acute gout?

Treatment for Acute Gout

First-line treatment for acute gout includes NSAIDs, oral colchicine, or corticosteroids, and must be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3

First-Line Treatment Options

All three first-line agents have comparable efficacy, so selection depends on patient-specific contraindications rather than superiority of one agent over another 1, 2, 3:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the attack has completely resolved 1, 2
• FDA-approved NSAIDs include naproxen 500mg twice daily, indomethacin, and sulindac 1
• Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 3
• When NSAIDs are used, add gastroprotection in patients with gastrointestinal risk factors 1

Colchicine

• Recommended 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, 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
• High-dose colchicine regimens should be avoided—they cause significant gastrointestinal toxicity without additional benefit 3

Corticosteroids

• Considered first-line therapy due to favorable safety profile and low cost 1, 2
• Oral prednisolone 35 mg daily for 5 days is effective 2
• Alternative routes include intra-articular injection (highly effective for single joint involvement) and intramuscular administration 1, 3
• Use with caution in diabetic patients due to potential hyperglycemia 1
• Preferred option in patients with renal impairment where NSAIDs and colchicine are problematic 3

Treatment Selection Algorithm

Base your choice on the following patient factors:

Renal Impairment

• Corticosteroids are the safest choice 3
• NSAIDs should be avoided 1, 3
• Colchicine requires dose adjustment: for severe impairment (CrCl <30 mL/min), use single dose of 0.6 mg followed by 0.3 mg one hour later, and do not repeat for at least 2 weeks 4

Cardiovascular Disease

• Choose colchicine or corticosteroids over NSAIDs 1
• NSAIDs increase cardiovascular risk in this population 1

Gastrointestinal Risk

• Avoid NSAIDs or use with gastroprotection 1
• Colchicine or corticosteroids are preferred 1

Diabetes

• Use corticosteroids with caution and monitor glucose closely 1
• NSAIDs or colchicine are preferred in poorly controlled diabetes 1

Multiple Joint Involvement or Severe Pain (≥7/10)

• Consider combination therapy: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 3

Critical Management Principles

• Initiate treatment within 24 hours of symptom onset—this is the most important determinant of therapeutic success 1, 2, 3
• Continue treatment at full dose until the gouty attack has completely resolved 1
• Do NOT discontinue urate-lowering therapy (if already prescribed) during the acute attack—this is a common pitfall that worsens outcomes 1, 2, 3
• Educate patients to self-medicate at the first warning symptoms ("pill in the pocket" approach) 3

Management of Inadequate Response

• Consider inadequate response if there is <20% improvement in pain within 24 hours or <50% improvement after 24 hours 3
• For inadequate response to monotherapy, switch to another first-line agent or add a second agent 1, 3
• For severe refractory attacks, IL-1 inhibitors (canakinumab) may be considered, though this remains off-label 3, 5

Important Drug Interactions and Dose Adjustments

Colchicine has critical drug interactions that can cause fatal toxicity:

• Contraindicated with strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, atazanavir, etc.) 4
• If strong CYP3A4 inhibitors cannot be avoided, reduce colchicine dose to 0.6 mg × 1 dose followed by 0.3 mg 1 hour later, and do not repeat for at least 3 days 4
• For prophylaxis with strong CYP3A4 inhibitors, reduce to 0.3 mg once daily or 0.3 mg every other day 4

Prophylaxis After Acute Attack

• Prophylaxis is strongly recommended when starting urate-lowering therapy 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
• Inadequate duration of prophylaxis leads to breakthrough flares and poor medication adherence—this is a common pitfall 2, 3

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 3
• Using high-dose colchicine regimens (causes severe GI toxicity without benefit) 3
• Discontinuing urate-lowering therapy during acute flares 2, 3
• Inadequate prophylaxis duration when initiating urate-lowering therapy 2, 3
• Missing critical drug interactions with colchicine, particularly with CYP3A4 inhibitors 3, 4