Treatment of Acute Gout Exacerbation
Initiate pharmacologic treatment within 24 hours of symptom onset using corticosteroids, NSAIDs, or low-dose colchicine as first-line therapy, with corticosteroids preferred in most patients due to superior safety profile and lower cost. 1
Immediate Management Principles
- Start treatment as early as possible – ideally within 24 hours of flare onset to optimize pain relief 1
- Continue ongoing urate-lowering therapy (ULT) without interruption during the acute attack 1
- Educate patients to self-medicate at the first warning symptoms of a flare 1
First-Line Pharmacologic Options
Corticosteroids (Preferred First-Line)
Corticosteroids should be considered as first-line therapy because they are generally safer than NSAIDs and colchicine, equally effective, and low-cost 1
Dosing regimens: 1
- Oral prednisone: 0.5 mg/kg/day (or 30-35 mg/day) for 5-10 days at full dose, then stop OR taper over 7-10 days
- Intramuscular: Triamcinolone acetonide 60 mg as single injection
- Intra-articular: Dose varies by joint size (particularly effective for monoarticular involvement)
Key advantages: Fewer adverse effects than NSAIDs, especially regarding gastrointestinal complications 1
Contraindications: Systemic fungal infections 1
NSAIDs (Alternative First-Line)
Use full FDA-approved doses for acute pain/gout treatment and continue at full dose until complete resolution 1
FDA-approved agents for gout: 1
- Naproxen
- Indomethacin
- Sulindac
- Other NSAIDs are also effective
Important considerations:
- No evidence that indomethacin is superior to other NSAIDs despite common practice 1
- Add proton pump inhibitor where gastrointestinal risk factors exist 1
- Contraindications: Renal disease, heart failure, cirrhosis 1
Colchicine (Alternative First-Line)
Use low-dose colchicine regimen only – equally effective as high-dose with significantly fewer gastrointestinal adverse effects 1
- If NOT already on prophylactic colchicine: 1.2 mg loading dose, then 0.6 mg one hour later
- Must be started within 12-36 hours of symptom onset for optimal efficacy 1
- If already on prophylactic colchicine: Choose alternative therapy (NSAID or corticosteroid) 1
Critical drug interactions and contraindications: 1, 2
- Avoid in severe renal impairment (CrCl <30 mL/min) 1
- Contraindicated with strong P-glycoprotein or CYP3A4 inhibitors (cyclosporine, clarithromycin) 1
- For dialysis patients: Single 0.6 mg dose only, not repeated more than once every two weeks 2
Second-Line Options
IL-1 Inhibitors
Consider IL-1 blockers (canakinumab) only when corticosteroids, NSAIDs, and colchicine are all contraindicated or ineffective 1
Key points:
- High-quality evidence supports efficacy 1
- Contraindication: Current infection 1
- Significantly more expensive than first-line options 1
- Not FDA-approved for gout at time of 2012 guidelines 1
Adjunctive Measures
- Topical ice application is conditionally recommended as adjuvant therapy 1
- Rest the affected joint during acute inflammation 3
Common Pitfalls to Avoid
- Do not delay treatment – efficacy decreases significantly after 24 hours 1
- Do not use high-dose colchicine – no additional benefit with substantially more adverse effects 1
- Do not stop urate-lowering therapy during acute flare 1
- Do not assume indomethacin is superior to other NSAIDs 1
- Do not use colchicine for acute treatment if patient already on prophylactic colchicine 1
- Do not overlook renal function when dosing colchicine or NSAIDs 1, 2
Special Populations
- Avoid colchicine and NSAIDs in severe renal disease
- Corticosteroids become preferred option
- Adjust colchicine dosing based on creatinine clearance
Elderly patients: 1
- Corticosteroids particularly appropriate due to lower risk profile
- NSAIDs carry higher risk of adverse effects
NPO (nothing by mouth) patients: 1
- Use parenteral corticosteroids (intramuscular, intravenous, or intra-articular)
Treatment Duration
Continue therapy at full dose until complete resolution of the acute attack 1