What is the recommended treatment for an acute case of gout?

Treatment for Acute Gout

For an acute gout attack, initiate treatment within 24 hours with first-line therapy: NSAIDs (naproxen 500mg twice daily), colchicine (1.2mg followed by 0.6mg one hour later), or corticosteroids (prednisolone 35mg daily for 5 days or prednisone 0.5mg/kg daily for 5-10 days), selecting based on patient comorbidities and contraindications. 1

Treatment Selection Algorithm

For mild to moderate pain (≤6/10) with single joint involvement:

• Use monotherapy with any first-line agent 1
• NSAIDs at full FDA-approved doses (naproxen 500mg twice daily, indomethacin, or sulindac) until complete resolution 2, 3
• Low-dose colchicine (1.2mg then 0.6mg one hour later, maximum 1.8mg over one hour) is as effective as higher doses with fewer GI side effects 1, 2
• Corticosteroids (prednisolone 35mg for 5 days, or prednisone 0.5mg/kg daily for 5-10 days) 1

For severe pain (>6/10) or polyarticular involvement:

• Use combination therapy 1
• Effective combinations include: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 1

Comorbidity-Based Selection

Renal impairment:

• Corticosteroids are preferred and safer than NSAIDs or colchicine 1, 2
• NSAIDs are contraindicated in renal disease 2
• Colchicine requires dose adjustment 2

Diabetes:

• NSAIDs or colchicine preferred over corticosteroids due to hyperglycemia risk 1, 2

Cardiovascular disease:

• Avoid NSAIDs; use colchicine or corticosteroids 2

Gastrointestinal risk factors:

• Corticosteroids or low-dose colchicine preferred over NSAIDs 1, 2
• If NSAIDs used, add gastroprotection 2

Heart failure or cirrhosis:

• NSAIDs contraindicated 2

Critical Timing and Principles

• Treatment must begin within 24 hours of symptom onset for optimal effectiveness 1, 4, 2
• Colchicine is most effective when started within 36 hours 4, 2
• Continue treatment at full dose until complete symptom resolution 2
• Do not discontinue existing urate-lowering therapy during an acute attack 1, 4, 2

Evidence on Specific Agents

NSAIDs:

• No evidence that indomethacin is superior to other NSAIDs 1
• In acute gout, naproxen shows significant clearing of inflammatory changes within 24-48 hours 3
• Naproxen causes statistically less gastric bleeding than aspirin 3

Colchicine:

• Low-dose regimen (1.2mg + 0.6mg) equally effective as high-dose with significantly fewer GI adverse effects 1, 4
• Common side effects include diarrhea, nausea, vomiting, and abdominal pain 2
• Watch for drug interactions, particularly in renal impairment 4

Corticosteroids:

• Triamcinolone acetonide 60mg IM is as safe and effective as indomethacin, with symptom resolution averaging 7 days 5
• Particularly useful when NSAIDs contraindicated 5

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 4
• Using high-dose colchicine causes significant GI toxicity without additional benefit 4
• Stopping urate-lowering therapy during flares worsens and prolongs the attack 4
• Combining NSAIDs with systemic corticosteroids increases GI toxicity risk 4
• Failing to consider colchicine drug interactions can lead to serious toxicity 4

Inadequate Response

• If monotherapy fails, add a second agent from a different class 2
• Continue full-dose treatment until complete resolution 2

Patient Education

• Educate patients to initiate treatment at first signs of an acute attack 1
• Ensure understanding that continuing urate-lowering therapy during attacks is essential 4