What is the initial management of gout in the emergency department (ED)?

Emergency Department Management of Acute Gout

Immediate First-Line Treatment Options

For acute gout in the ED, initiate treatment immediately with NSAIDs, corticosteroids, or colchicine—all are equally appropriate first-line options, with selection based on patient comorbidities and time since symptom onset. 1, 2

NSAIDs (First-Line)

• Administer full anti-inflammatory doses immediately (e.g., naproxen 500 mg twice daily or indomethacin 50 mg three times daily) 1, 3
• Continue until complete symptom resolution 3
• Add proton pump inhibitor if patient has GI risk factors 1
• Avoid in patients with: severe renal impairment (CrCl <30 mL/min), heart failure, cirrhosis, active GI bleeding, or recent cardiovascular events 1, 2

Corticosteroids (First-Line—Preferred in Renal Disease)

Corticosteroids are the safest option in patients with renal impairment, heart failure, or multiple comorbidities 2, 4

For monoarticular or oligoarticular involvement (1-2 joints):

• Perform arthrocentesis and inject intra-articular corticosteroid (triamcinolone acetonide 40 mg for large joints like knee, 20 mg for smaller joints) 1, 4
• This provides rapid relief with minimal systemic effects 1

For polyarticular involvement (≥3 joints):

• Oral prednisone 30-35 mg daily for 3-5 days 1, 2
• Alternative: prednisone 0.5 mg/kg/day for 5-10 days, then taper over 7-10 days 1, 4
• Methylprednisolone dose pack is acceptable but less preferred 1

For NPO patients:

• Intramuscular triamcinolone acetonide 60 mg single dose 1

Colchicine (First-Line—Time-Sensitive)

Colchicine is ONLY effective when started within 12 hours of symptom onset 1, 2

Dosing regimen:

• 1.2 mg (two 0.6 mg tablets) initially, followed by 0.6 mg one hour later 1, 3, 5
• Do NOT repeat this loading dose for at least 3 days 5
• After initial loading, may continue 0.6 mg twice daily if started >12 hours after loading 1

Critical contraindications and dose adjustments:

• Avoid in severe renal impairment (CrCl <30 mL/min) 1
• For dialysis patients: single 0.6 mg dose only, not to be repeated more than once every 2 weeks 5
• Do NOT use with strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, HIV protease inhibitors) 1, 5
• Expect GI side effects (diarrhea, nausea) in 23% even with low-dose regimen 1

Combination Therapy for Severe Presentations

For severe pain (≥7/10) or polyarticular involvement affecting multiple large joints, initiate combination therapy with full doses of two agents simultaneously 1

Acceptable combinations:

• Colchicine + NSAIDs 1
• Oral corticosteroids + colchicine 1
• Intra-articular corticosteroids + any other modality 1

NEVER combine NSAIDs with systemic corticosteroids due to synergistic GI toxicity risk 1

Critical Management Principles

Timing

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 3, 4
• Earlier treatment = better response regardless of agent chosen 1, 6

Urate-Lowering Therapy (ULT)

• Do NOT initiate ULT in the ED during an acute attack 1, 2
• If patient is already on ULT (allopurinol, febuxostat), DO NOT stop it during the acute flare 3, 4

Inadequate Response Definition

If patient shows <20% pain improvement within 24 hours OR <50% improvement after 24 hours:

• Consider alternative diagnoses (septic arthritis, pseudogout) 1
• Switch to different monotherapy OR add second agent 1, 3

Special Populations

Severe Renal Impairment/ESRD

• Corticosteroids are first-line (oral or intra-articular) 2, 4
• Colchicine: maximum 0.6 mg single dose, repeat no more than once every 2 weeks 5
• Avoid NSAIDs completely 1, 2

Patients on Chronic Diuretics

• Consider switching diuretic if possible (use losartan for hypertension instead) 1
• Otherwise, proceed with standard acute treatment 1

Patients Unable to Take Oral Medications

• Intra-articular corticosteroids for 1-2 joints 1
• Intramuscular triamcinolone acetonide 60 mg 1
• Consider IV corticosteroids if polyarticular 1

Common ED Pitfalls to Avoid

1. Performing arthrocentesis without crystal confirmation: Only 8% of ED gout visits include arthrocentesis, yet crystal confirmation is diagnostic gold standard 7
2. Prescribing opiates instead of anti-inflammatory drugs: One study found opiates given in 54% of ED visits while NSAIDs only 56%, despite opiates having no anti-inflammatory effect 7
3. Sending patients home without any anti-inflammatory medication: This occurred in 6% of ED visits in one study 7
4. Starting colchicine >12 hours after symptom onset: Efficacy drops dramatically after this window 1, 2
5. Using high-dose colchicine regimens: The old "1.2 mg then 0.6 mg every hour" regimen causes 77% diarrhea rate vs 23% with low-dose 1

ED Discharge Planning

• Continue anti-inflammatory treatment until complete symptom resolution 3
• Arrange rheumatology or primary care follow-up within 1-2 weeks for ULT discussion 1, 2
• ULT is indicated for: recurrent flares (≥2/year), tophi, urate arthropathy, renal stones, or young age (<40 years) with very high uric acid (>8 mg/dL) 1, 2
• Counsel on lifestyle modifications: limit alcohol (especially beer), avoid high-fructose corn syrup beverages, reduce purine-rich foods (organ meats, shellfish) 2, 8