What medications are recommended to treat gout?

Treatment of Acute Gout

Immediate First-Line Pharmacologic Options

For acute gout, initiate treatment within 24 hours of symptom onset with one of three equally effective first-line options: NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or corticosteroids (oral prednisone 0.5 mg/kg/day or equivalent). 1, 2

NSAIDs (Preferred in Most Patients)

• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 1, 3, 4
• Administer at full FDA-approved anti-inflammatory doses and continue until the attack completely resolves 1, 3, 2
• No single NSAID is more effective than another—the key is rapid initiation, not agent selection 1, 5
• Example dosing: Indomethacin 50 mg three times daily for 2-3 days, then 25 mg three times daily for 3-5 days 3

Contraindications: Avoid NSAIDs in patients with severe renal impairment (GFR <30 mL/min), active GI bleeding or ulceration, heart failure, or cirrhosis 1, 3, 2

Colchicine (Most Effective When Started Early)

• Recommended dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later (maximum 1.8 mg over one hour) 1, 6, 4
• Must be initiated within 36 hours of symptom onset for optimal efficacy 1, 6
• This low-dose regimen is as effective as high-dose colchicine (4.8 mg) but with significantly fewer gastrointestinal side effects 6, 4

Absolute contraindications:

• Concurrent use of strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir) or P-glycoprotein inhibitors (cyclosporine) 1, 6, 4
• Severe renal impairment (GFR <30 mL/min) combined with hepatic impairment 6, 4

Corticosteroids (First-Line When NSAIDs/Colchicine Contraindicated)

• Oral prednisone 0.5 mg/kg/day (typically 30-35 mg/day) for 5-10 days at full dose, then stop or taper over 7-10 days 1, 2
• Alternative routes: intra-articular injection for monoarticular gout, or intramuscular triamcinolone acetonide 60 mg 1, 2
• Corticosteroids should be considered first-line therapy in patients without contraindications due to superior safety profile and low cost 1, 2

Caution: Monitor blood glucose in diabetic patients; avoid in patients with systemic fungal infections 1, 2

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Critical Treatment Principles

Timing Is Everything

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 1, 3, 2
• Delaying beyond 36 hours significantly reduces effectiveness, particularly for colchicine 1, 6

Do NOT Interrupt Urate-Lowering Therapy

• Continue ongoing allopurinol or febuxostat during acute attacks—stopping these medications can worsen or prolong flares 1, 3, 2

Inadequate Response Protocol

• If <50% pain improvement at 24 hours, add a second agent from a different class 1
• For severe polyarticular attacks, combination therapy (e.g., colchicine + NSAID) may be appropriate initially 6, 2

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Special Populations and Contraindications

Renal Impairment

• NSAIDs are contraindicated in severe renal disease 1, 3
• Colchicine requires dose adjustment: avoid if GFR <30 mL/min, especially with concurrent CYP3A4 inhibitors 6, 4
• Corticosteroids are the safest option in advanced renal disease 1, 2

Cardiovascular Disease

• Prefer colchicine or corticosteroids over NSAIDs due to cardiovascular risks with NSAIDs 2

Gastrointestinal Risk

• If NSAIDs are necessary, coadminister proton pump inhibitor 1
• Consider corticosteroids or colchicine as alternatives 1, 2

NSAID Allergy

• Colchicine is safe in NSAID-allergic patients—it works through a completely different mechanism (microtubule inhibition) with no cross-reactivity 6
• Corticosteroids are another excellent alternative 6, 2

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Prophylaxis When Initiating Urate-Lowering Therapy

When starting allopurinol or febuxostat, provide prophylaxis to prevent treatment-induced flares:

• First-line prophylaxis: Low-dose colchicine 0.6 mg once or twice daily 1, 2
• Second-line: Low-dose NSAID (e.g., naproxen 250 mg twice daily) with PPI 1
• Third-line: Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs contraindicated 1

Duration: Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate (<6 mg/dL) if no tophi present 1, 2

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Common Pitfalls to Avoid

1. Using high-dose colchicine regimens (>1.8 mg in first hour)—provides no additional benefit but substantially increases gastrointestinal toxicity 6, 4

2. Stopping urate-lowering therapy during acute attacks—this worsens crystal mobilization and prolongs flares 1, 3

3. Delaying treatment beyond 24-36 hours—significantly reduces efficacy of all agents 1, 3, 2

4. Using colchicine with strong CYP3A4 inhibitors—can cause fatal colchicine toxicity 1, 6, 4

5. Underdosing NSAIDs—must use full anti-inflammatory doses, not analgesic doses 1, 3

6. Treating pain without addressing inflammation—colchicine is not an analgesic and works by reducing neutrophil migration 4, 7