What is the recommended initial treatment for a patient experiencing a gout attack?

Initial Treatment of Acute Gout Attack

For an acute gout attack, initiate treatment within 24 hours with monotherapy using NSAIDs at full anti-inflammatory doses, oral colchicine (1.2 mg followed by 0.6 mg one hour later), or systemic corticosteroids, with selection based on attack severity, number of joints involved, and patient comorbidities. 1, 2

Treatment Timing

• Start pharmacologic therapy within 24 hours of symptom onset to achieve optimal outcomes and better patient-reported pain reduction 1, 2
• Early treatment is the most important determinant of therapeutic success, more so than which specific agent is chosen 3

First-Line Monotherapy Options for Mild-to-Moderate Attacks

For attacks with pain ≤6/10 on a visual analogue scale involving 1-3 small joints or 1-2 large joints, choose one of the following 1:

NSAIDs (Evidence A)

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1, 2
• FDA-approved options include naproxen (Evidence A), indomethacin (Evidence A), or sulindac (Evidence B) 1
• No single NSAID is preferentially recommended over another 1
• Avoid in patients with heart failure, peptic ulcer disease, significant renal disease, or chronic kidney disease 2

Oral Colchicine (Evidence B)

• Only effective when started within 36 hours of symptom onset 1, 2, 4
• Dosing: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg) 1, 5
• This low-dose regimen (38% response rate) is as effective as higher doses (33% response rate) with fewer gastrointestinal side effects compared to the older high-dose regimen 5
• After the initial loading doses, continue with prophylactic dosing (0.6 mg once or twice daily) 12 hours later until the attack resolves 1
• Requires dose adjustment in moderate-to-severe chronic kidney disease and with strong CYP3A4 inhibitors or P-glycoprotein inhibitors 1, 5

Systemic Corticosteroids (Evidence A)

• Oral prednisone or prednisolone 0.5 mg/kg per day (approximately 30-35 mg daily) for 5-10 days, then stop 1, 2
• Alternative: methylprednisolone dose pack with follow-up treatment as indicated 1
• Prednisolone 35 mg daily for 5 days is equally effective to naproxen 500 mg twice daily (44.7 mm vs 46.0 mm pain reduction on 100 mm scale, difference 1.3 mm) 6
• Particularly useful for patients with contraindications to NSAIDs or colchicine 2, 4

Intra-articular Corticosteroids

• Highly effective for single joint involvement (1-2 affected joints) 2, 4
• Perform arthrocentesis followed by injection of long-acting steroid such as triamcinolone acetonide 40-60 mg for large joints 1, 7
• Can be combined with oral agents 1

Combination Therapy for Severe Attacks

• For severe pain (>6/10) or polyarticular involvement (≥4 joints), use combination therapy with full doses of two agents 1, 4
• Acceptable combinations include 1:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids + any oral agent
• Do not combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1, 7

Management of Inadequate Response

• Inadequate response is defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours 2, 4
• If monotherapy fails, add a second appropriate agent or switch to combination therapy 1, 4
• Consider alternative diagnoses if response remains poor 4

Critical Management Principles

• Continue established urate-lowering therapy without interruption during the acute attack 1, 2, 7
• Stopping urate-lowering therapy during acute attacks worsens outcomes 2
• Continue the chosen treatment at full dose until the acute attack completely resolves 1, 2, 4
• Provide patient education on self-initiating treatment at the first sign of future attacks without needing to consult their healthcare provider each time 1

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness of all agents 2, 4
• Using colchicine after 36 hours of symptom onset reduces efficacy substantially 1, 2, 4
• Discontinuing urate-lowering therapy during acute flares leads to worse outcomes and poor medication adherence 2, 7
• Failing to adjust colchicine dosing for renal impairment or drug interactions can lead to serious toxicity 1, 5