What is the initial management of gout in the emergency department?

Emergency Department Management of Acute Gout

For acute gout in the emergency department, immediately initiate treatment with NSAIDs, oral corticosteroids, or colchicine based on patient comorbidities, with NSAIDs as first-line for most patients and corticosteroids preferred for those with renal impairment, heart failure, or multiple comorbidities. 1

Immediate Treatment Selection

First-Line Options (Choose One Based on Patient Factors)

NSAIDs (Preferred for most patients):

• Administer full anti-inflammatory doses immediately: naproxen 500 mg twice daily or indomethacin 50 mg three times daily, continuing until complete symptom resolution 1
• Add a proton pump inhibitor if GI risk factors are present 1
• Avoid NSAIDs completely in patients with: severe renal impairment (CrCl <30 mL/min), active heart failure, cirrhosis, active GI bleeding, or recent cardiovascular events 1
• NSAIDs are equally effective regardless of which specific agent is chosen; the critical factor is early initiation within 24 hours of symptom onset 2, 1

Oral Corticosteroids (Preferred for patients with contraindications to NSAIDs):

• Prednisolone 30-35 mg daily for 3-5 days (no taper needed for short course) 1, 3
• Alternative regimen: prednisone 0.5 mg/kg/day for 5-10 days, then taper over 7-10 days 1
• Corticosteroids are as effective as NSAIDs with fewer adverse effects in elderly patients and those with multiple comorbidities 2, 3
• Corticosteroids are the safest option and first-line choice for patients with renal impairment, heart failure, or multiple comorbidities 1, 3

Colchicine (Only effective if started within 12 hours of symptom onset):

• Dosing: 1.2 mg initially, followed by 0.6 mg one hour later 1
• Do not repeat this loading dose for at least 3 days 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg at 1 hour) is as effective as high-dose regimens but much better tolerated, with 23% vs 77% experiencing diarrhea 2
• Critical timing limitation: Colchicine loses effectiveness if not started within 12 hours of symptom onset 1

Intra-articular Corticosteroid Injection

For monoarticular or oligoarticular involvement (1-2 joints):

• Perform arthrocentesis and inject triamcinolone acetonide: 40 mg for large joints (knee, ankle) or 20 mg for smaller joints 1, 3
• This provides rapid relief with minimal systemic effects and is an excellent option for patients unable to take oral medications 2, 1

Combination Therapy for Severe Presentations

For severe pain (≥7/10 on pain scale) or polyarticular involvement affecting multiple large joints:

• Use full doses of two agents simultaneously 2, 1
• Acceptable combinations: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular corticosteroids + any other modality 2, 1
• Never combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 2, 1

Critical Timing Principle

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 1
• Earlier treatment results in better response regardless of which agent is chosen 1, 4
• The most important determinant of therapeutic success is not which medication is selected, but how soon treatment is initiated 4

Management of Patients Unable to Take Oral Medications (NPO)

For NPO patients:

• Intra-articular corticosteroid injection for 1-2 accessible joints (triamcinolone acetonide 40 mg for large joints) 2
• Intravenous or intramuscular methylprednisolone 0.5-2.0 mg/kg as initial dose 2
• Subcutaneous synthetic ACTH 25-40 IU with repeat doses as clinically indicated 2

Urate-Lowering Therapy Considerations in the ED

Do NOT initiate urate-lowering therapy (allopurinol, febuxostat) during an acute attack in the emergency department 1, 5

• Starting ULT during an acute flare can worsen and prolong symptoms 6
• However, if the patient is already on ULT, continue it—do not stop 5

Special Population Considerations

Severe renal impairment (CrCl <30 mL/min):

• Corticosteroids are first-line treatment 1, 3
• Avoid NSAIDs completely 1, 3
• Avoid or significantly reduce colchicine dose 3

Patients on chronic diuretics:

• Consider switching to losartan for hypertension management (has modest uricosuric effects) 5
• Proceed with standard acute treatment based on comorbidities 5

Inadequate Response to Initial Therapy

Define inadequate response as:

• <20% improvement in pain score within 24 hours, OR
• <50% improvement in pain score ≥24 hours after initiating therapy 2

Management approach:

• Consider alternative diagnoses to gout 2
• Switch to another monotherapy option 2
• Add a second recommended agent (combination therapy) 2

ED Discharge Planning

Continue anti-inflammatory treatment until complete symptom resolution 1, 5

Arrange follow-up within 1-2 weeks with rheumatology or primary care for:

• Discussion of urate-lowering therapy initiation 1
• ULT is indicated for: recurrent flares (≥2/year), tophi, radiographic damage, urolithiasis, or young age with very high uric acid 2, 1

Provide lifestyle counseling:

• Limit alcohol consumption (especially beer) 1, 7
• Avoid beverages with high-fructose corn syrup 1, 7
• Reduce intake of organ meats and shellfish 7
• Encourage low-fat dairy products and weight loss if obese 5, 7

Common Pitfalls to Avoid

• Failing to treat within 24 hours of symptom onset reduces treatment efficacy regardless of agent chosen 1, 4
• Using NSAIDs in patients with renal impairment or heart failure can cause serious complications 1
• Starting colchicine after 12 hours of symptom onset results in poor efficacy 1
• Combining NSAIDs with systemic corticosteroids increases GI bleeding risk 2, 1
• Initiating allopurinol during an acute attack can worsen and prolong the flare 6
• Prescribing opiates without anti-inflammatory medications—a study found that during 54% of ED visits opiates were given, but anti-inflammatory drugs were not given during >50% of visits, representing suboptimal care 8