From the Guidelines
The treatment of an acute gout attack should focus on reducing inflammation and pain as quickly as possible, with first-line medications including NSAIDs, colchicine, or corticosteroids, as recommended by the American College of Physicians 1.
Treatment Options
- NSAIDs (such as naproxen 500mg twice daily or indomethacin 50mg three times daily)
- Colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily)
- Corticosteroids (prednisone 30-40mg daily, tapered over 7-10 days)
Important Considerations
- Treatment should begin within 24 hours of symptom onset and continue until the attack resolves, typically 7-10 days
- Ice application for 20 minutes several times daily and rest of the affected joint can provide additional relief
- Patients should maintain adequate hydration and continue their usual urate-lowering therapy if already established
- Aspirin should be avoided as it can worsen gout attacks
- The choice between treatment options depends on patient comorbidities—NSAIDs should be avoided in those with kidney disease or peptic ulcers, while corticosteroids require caution in diabetics
Lifestyle Modifications
- Identifying and addressing triggers like alcohol consumption, purine-rich foods, and certain medications is important for patients with recurrent attacks
- Patients should receive advice regarding lifestyle modifications, including weight loss if appropriate, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, as recommended by the European League Against Rheumatism (EULAR) 1
Prophylaxis
- Prophylaxis against acute attacks during the first months of urate-lowering therapy is recommended, with low-dose colchicine or NSAIDs as appropriate options, as recommended by EULAR 1 and the American College of Rheumatology 1
From the FDA Drug Label
The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis.
The treatment of an acute gout attack can be done with Colchicine or Indomethacin.
- Colchicine: The recommended dose is 1.2 mg at the first sign of the flare, followed by 0.6 mg one hour later.
- Indomethacin: The drug label does not specify a dose for acute gout attack, but it has been found to be effective in relieving the symptoms of acute gouty arthritis 2 3.
From the Research
Treatment Options for Acute Gout Attack
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout, with most potent NSAIDs being probably useful in controlling pain and inflammatory signs of acute gouty arthritis 4.
- Colchicine is also widely used, but its toxicity, especially gastrointestinal adverse effects, is a major concern, and it should not be prescribed to patients with severe renal insufficiency or combined hepatic-renal insufficiency 4.
- Corticosteroids are probably a reasonable choice for patients in whom colchicine and NSAIDs may be hazardous or for those with a history of previous intolerance to these drugs 4.
- Low-certainty evidence suggests that NSAIDs may improve pain at 24 hours and may have little to no effect on function, inflammation, or adverse events for treatment of acute gout 5.
- Moderate-certainty evidence shows that COXIBs and non-selective NSAIDs are probably equally beneficial with regards to improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs probably increase withdrawals due to adverse events and total adverse events 5.
- Systemic glucocorticoids and NSAIDs probably are equally beneficial in terms of pain relief, improvement in function, and treatment success, with similar withdrawals due to adverse events, but NSAIDs probably result in more total adverse events 5.
Considerations for Treatment
- Comorbidities should always be kept in mind when prescribing NSAIDs, as patients with previous or recent gastrointestinal bleeding, those receiving anticoagulant therapy or with haemorrhage diathesis, and those with renal insufficiency are at risk of developing severe adverse effects from NSAID administration 4.
- Pharmacokinetic properties should be taken into account when selecting an NSAID for the treatment of gout, as rapid absorption and a short half-life may help to avoid accumulation in patients with subclinical renal function impairment 4.
- The choice of a drug for the treatment of acute gout will depend on the balance between its efficacy and the potential adverse effects in a particular patient 4.
- Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating any urate-lowering therapy in order to prevent acute gouty arthritis for a period of at least 6 months 6.
Other Treatment Options
- Adrenocorticotropic hormone (ACTH) is suggested to be efficacious in acute gout 7.
- The IL-1β inhibitory antibody, canakinumab, was effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 7.
- Xanthine oxidase inhibitor therapy remains the consensus first-line treatment option for the prevention of recurrent gout 6.
- Add-on therapies that reduce serum urate concentration include traditional uricosuric agents and a novel uric acid reabsorption inhibitor 6.