Initial Treatment for Acute Gouty Arthritis
For acute gouty arthritis, initiate pharmacologic therapy within 24 hours of symptom onset using NSAIDs, oral colchicine, or corticosteroids as first-line monotherapy options, with selection based on pain severity, number of joints involved, and patient comorbidities. 1, 2
Treatment Timing and General Principles
- Start treatment within 24 hours of symptom onset for optimal pain relief and inflammation control 1, 2, 3
- Continue any established urate-lowering therapy (ULT) without interruption during the acute attack—stopping ULT can worsen and prolong the flare 1, 2, 3
- Provide patient education on recognizing symptoms early and self-initiating treatment without needing to contact their provider for each attack 1
First-Line Monotherapy Options (Equally Appropriate)
The American College of Rheumatology does not rank one therapeutic class over another, making all three options equally valid first-line choices 1:
NSAIDs
- Use full FDA-approved anti-inflammatory doses until the attack completely resolves 2
- Indomethacin 50 mg three times daily until pain is tolerable, then rapidly taper to cessation (pain relief typically within 2-4 hours, with tenderness/heat subsiding in 24-36 hours) 4
- Naproxen at full anti-inflammatory doses is also FDA-approved with Level A evidence 1, 2
- For patients with GI contraindications, celecoxib 800 mg once, then 400 mg on day 1, followed by 400 mg twice daily for one week may be used cautiously, though risk-benefit ratio is not fully established 1
- Continue NSAID therapy for 7-10 days or until complete resolution 1
Oral Colchicine
- Most effective when started within 36 hours of symptom onset 2
- Dosing: 1.2 mg initially, followed by 0.6 mg one hour later 2
- This low-dose regimen has similar efficacy to high-dose regimens but significantly fewer side effects 5
Corticosteroids
- Oral prednisone/prednisolone 30-40 mg daily for 7-10 days, then stop 1
- Alternative: Methylprednisolone dose pack with follow-up treatment as indicated 1
- Intra-articular injection (dose varies by joint size) is particularly useful for monoarticular or oligoarticular involvement 1, 2
- Intramuscular triamcinolone acetonide 60 mg followed by oral prednisone is another option 1
Treatment Selection Algorithm
For Mild-to-Moderate Pain (≤6/10 on pain scale) with 1-3 Small Joints or 1-2 Large Joints:
- Select monotherapy with NSAIDs, colchicine, or corticosteroids 1, 2
- Base choice on:
- Renal function: Avoid NSAIDs and adjust colchicine dose in renal impairment 1
- GI risk: Avoid NSAIDs if peptic ulcer disease or high GI bleeding risk; consider corticosteroids 1
- Cardiovascular disease: Use NSAIDs cautiously; corticosteroids may be preferred 1
- Prior response: Use what has worked previously for the patient 1
For Severe Pain or Polyarticular Involvement:
- Combination therapy is appropriate using full doses of two agents simultaneously 1
- Acceptable combinations include:
- Do NOT combine NSAIDs with systemic corticosteroids due to synergistic GI toxicity risk 1, 3
Monitoring Treatment Response
- Inadequate response is defined as:
- <20% improvement in pain within 24 hours, OR
- <50% improvement after 24 hours 2
- If inadequate response occurs:
Critical Pitfalls to Avoid
- Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
- Stopping urate-lowering therapy during an acute attack worsens and prolongs the flare 1, 3, 5
- Combining NSAIDs with systemic corticosteroids increases GI toxicity risk 1, 3
- Using high-dose colchicine regimens provides no additional benefit but causes significantly more adverse effects 5
- Prescribing NSAIDs without considering renal function, GI risk, and cardiovascular disease, particularly in elderly patients 1