Management of Gouty Arthritis of the Great Toe
Initiate pharmacologic treatment within 24 hours of symptom onset using NSAIDs, colchicine, or corticosteroids as monotherapy for this single joint attack, and continue treatment at full dose until complete symptom resolution. 1, 2
Immediate Treatment Approach
Timing is Critical
- Start therapy within 24 hours of symptom onset for optimal outcomes 1, 2, 3
- Colchicine is only effective if started within 36 hours of symptom onset 1, 2
- Delaying treatment beyond 24 hours significantly reduces effectiveness 3, 4
First-Line Monotherapy Options
For a single great toe attack (mild-to-moderate severity), choose one of the following based on patient comorbidities and contraindications 1, 2:
NSAIDs (Evidence Level A)
- Use full FDA-approved anti-inflammatory doses until complete attack resolution 1, 2
- FDA-approved options for acute gout: 1, 2
- Naproxen (Evidence A)
- Indomethacin (Evidence A) 5
- Sulindac (Evidence B)
- Continue at full dose for 5-14 days until symptoms completely resolve 2
- Contraindications: Active GI bleeding, severe renal impairment, cardiovascular disease 1
Colchicine (Evidence Level A)
- Dosing regimen: 1.2 mg loading dose, followed by 0.6 mg one hour later 1, 2, 3
- Then continue 0.6 mg once or twice daily starting 12 hours after loading dose until attack resolves 2
- Low-dose regimen is as effective as high-dose with fewer gastrointestinal side effects 3
- Must be started within 36 hours of symptom onset 1, 2
- Requires dose adjustment in chronic kidney disease and for drug interactions 1
Corticosteroids (Evidence Level A)
- Oral prednisone or prednisolone at full anti-inflammatory doses 1, 3
- Can be used orally or via intra-articular injection for single joint involvement 3
- Preferred in patients with: renal impairment or contraindications to NSAIDs/colchicine 3
Critical Management Principles
Do NOT Stop Urate-Lowering Therapy
- If the patient is already on allopurinol or other urate-lowering therapy (ULT), continue it without interruption during the acute attack 1, 2, 4
- Stopping ULT during acute flares worsens and prolongs the attack 3, 4
Patient Education
- Instruct patients to self-initiate treatment at first sign of attack without waiting for physician consultation 1, 2
- Educate on dietary and lifestyle triggers 1
Prophylaxis Strategy
When Initiating Urate-Lowering Therapy
If this is a new diagnosis and you plan to start allopurinol or other ULT after the acute attack resolves:
- Start prophylaxis simultaneously with ULT initiation 1, 2, 4, 6
- First-line prophylactic options: 1, 2, 4
- Colchicine 0.6 mg once or twice daily, OR
- Low-dose NSAID with PPI when indicated
- Duration: Continue for at least 6 months, or 3 months after achieving target uric acid (<6 mg/dL) with no tophi 2, 4
- Prophylaxis prevents acute flares that commonly occur when starting ULT 6, 7
Allopurinol Initiation (if starting ULT)
- Start low at 100 mg daily and increase by 100 mg weekly until serum uric acid ≤6 mg/dL 6
- Maximum dose 800 mg daily 6
- Must provide colchicine or NSAID prophylaxis during titration 6
Common Pitfalls to Avoid
- Never combine NSAIDs with systemic corticosteroids - increases GI toxicity risk without additional benefit 3, 4
- Never use high-dose colchicine regimens - causes significant GI side effects without additional benefit 3
- Never stop established ULT during acute attacks - worsens and prolongs the attack 1, 3, 4
- Never start ULT without prophylaxis - triggers recurrent acute attacks 4, 6
- Never delay treatment - effectiveness decreases significantly after 24 hours 2, 3, 4
- Check for colchicine drug interactions, particularly with CYP3A4 inhibitors and P-glycoprotein inhibitors 3