What is the recommended treatment for acute gout?

Treatment of Acute Gout

First-Line Treatment Options

For acute gout, initiate treatment within 24 hours of symptom onset with NSAIDs, oral colchicine, or corticosteroids—all are equally effective first-line options, with corticosteroids offering the safest profile in most patients. 1, 2, 3

The choice among these three agents depends on patient-specific contraindications rather than efficacy differences:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until complete resolution of the attack 1
• FDA-approved options include naproxen 500 mg twice daily, indomethacin, and sulindac 1, 4
• Contraindicated in renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 3
• When used, add gastroprotection in patients with GI risk factors 1

Colchicine

• Most effective when started within 36 hours of symptom onset 1, 2
• Recommended low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 2, 5
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 2
• Common side effects include diarrhea, nausea, vomiting, and abdominal cramping 1
• Requires dose adjustment in renal impairment: For severe renal impairment (CrCl <30 mL/min), treatment course should not be repeated more than once every two weeks; for dialysis patients, use single 0.6 mg dose only 5
• Drug interactions are critical: Dose must be reduced by 50-75% when used with strong CYP3A4 inhibitors (clarithromycin, protease inhibitors) 5

Corticosteroids

• Considered first-line therapy due to safety profile and low cost 1, 2, 3
• Prednisolone 35 mg daily for 5 days is effective 2, 3
• Available as oral, intra-articular, or intramuscular administration 1
• Safest option in patients with renal impairment, cardiovascular disease, or GI risk 1, 3
• Use with caution in diabetes due to potential hyperglycemia 1
• Meta-analysis shows corticosteroids have similar efficacy to NSAIDs but with lower risk of indigestion, nausea, and vomiting 6

Treatment Algorithm Based on Severity

Mild to Moderate Pain (≤6/10) with Limited Joint Involvement

• Monotherapy with any first-line agent is appropriate 3
• Select based on contraindications outlined above

Severe Pain (≥7/10) or Polyarticular Involvement

• Combination therapy is recommended 3
• Effective combinations include:
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality 3

Critical Management Principles

Timing

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 1, 2, 3
• The most important determinant of success is how soon therapy begins, not which agent is chosen 7

Continue Existing Urate-Lowering Therapy

• Do not discontinue urate-lowering therapy during an acute attack if already prescribed 1, 2
• This is a common pitfall that worsens outcomes 2

Inadequate Response

• Defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours 3
• Switch to another monotherapy or add a second recommended agent 1, 3

Special Populations

Renal Impairment

• Corticosteroids are the safest choice 3
• NSAIDs are contraindicated 1
• Colchicine requires dose adjustment as detailed above 5

Cardiovascular Disease

• Use colchicine or corticosteroids; avoid NSAIDs 1

Hepatic Impairment

• Mild to moderate: no dose adjustment needed but monitor closely 5
• Severe: treatment course with colchicine should not be repeated more than once every two weeks 5

Prophylaxis When Initiating Urate-Lowering Therapy

Prophylaxis is strongly recommended when starting urate-lowering therapy to prevent acute flares 1, 2, 8:

• Options include low-dose colchicine (0.6 mg once or twice daily), low-dose NSAIDs, or low-dose prednisone 1, 2
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi present 1
• If tophi present, continue for 6 months after achieving target serum urate 1

Common Pitfalls to Avoid

• Using high-dose colchicine regimens (outdated and causes more side effects) 2
• Discontinuing urate-lowering therapy during acute flares 2
• Inadequate duration of prophylaxis when initiating urate-lowering therapy 2
• Delaying treatment beyond 24 hours of symptom onset 1, 2
• Treating acute gout with colchicine in patients already on prophylactic colchicine who are also taking CYP3A4 inhibitors 5