What is the recommended management for acute gout?

Management of Acute Gout

First-Line Treatment: Choose Corticosteroids, NSAIDs, or Colchicine

For acute gout, initiate treatment within 24 hours of symptom onset with corticosteroids, NSAIDs, or colchicine—all three are equally effective for pain relief, but corticosteroids should be considered first-line in most patients due to superior safety profile and lower cost. 1, 2

Treatment Selection Algorithm

Corticosteroids (Preferred First-Line)

• Prednisolone 30-35 mg daily for 3-5 days is the recommended regimen 1, 2
• Safer than NSAIDs with fewer adverse effects in head-to-head trials 1, 3
• Lowest cost option among the three agents 1
• Preferred in patients with renal disease, heart failure, cirrhosis, or cardiovascular disease 1, 2, 4
• Intra-articular injection is appropriate for monoarticular gout 1, 2
• Caution: Monitor for hyperglycemia in diabetics, avoid in systemic fungal infections 1, 4

NSAIDs (Alternative First-Line)

• Use full FDA-approved anti-inflammatory doses until complete resolution 1, 4
• No single NSAID is superior—naproxen, indomethacin, and sulindac are FDA-approved, but any NSAID at full anti-inflammatory dose is effective 1
• Add proton pump inhibitor in patients with gastrointestinal risk factors 2
• Contraindicated in renal disease (any stage), heart failure, cirrhosis, and active peptic ulcer disease 1, 4
• Lower risk of indigestion, nausea, and vomiting compared to NSAIDs favors corticosteroids 3

Colchicine (Alternative First-Line)

• Most effective when started within 12-36 hours of symptom onset 1, 2, 5
• Dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2, 4, 5
• Low-dose regimen equally effective as high-dose with significantly fewer gastrointestinal side effects 2, 4
• More expensive than corticosteroids or NSAIDs 1
• Contraindicated with severe renal impairment (GFR <30 mL/min) and concurrent use of strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) 2, 5

Severity-Based Approach

Mild to Moderate Pain (≤6/10 on pain scale) with 1-3 small joints or 1-2 large joints:

• Monotherapy with any first-line agent is appropriate 1, 4

Severe Pain (≥7/10) or Polyarticular Involvement (≥4 joints):

• Combination therapy is recommended 1, 6
• Effective combinations: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality 1, 6
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 2

Special Population Adjustments

Renal Impairment:

• Corticosteroids are safest option 1, 2, 6
• Mild-moderate impairment (CrCl 30-80 mL/min): Standard colchicine dosing acceptable with close monitoring 5
• Severe impairment (CrCl <30 mL/min): Colchicine 0.6 mg single dose, repeat no more than once every 2 weeks 5
• Dialysis patients: Colchicine 0.6 mg single dose, repeat no more than once every 2 weeks 5
• NSAIDs contraindicated in any degree of renal disease 1, 4

Hepatic Impairment:

• Mild-moderate: Standard dosing with close monitoring for all agents 5
• Severe: Colchicine treatment course should not be repeated more than once every 2 weeks 5

Elderly Patients:

• Corticosteroids preferred due to lower risk of serious adverse effects compared to NSAIDs 4
• Dose selection should account for decreased renal function 5

Critical Management Principles

Timing:

• Treatment must be initiated within 24 hours of symptom onset for optimal efficacy 1, 2, 4
• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms 2

Urate-Lowering Therapy:

• Do not stop established urate-lowering therapy during an acute attack 1, 4
• Do not initiate new urate-lowering therapy during acute attack 1

Inadequate Response:

• Defined as <20% pain improvement within 24 hours or <50% improvement at 48 hours 1
• Add a second appropriate agent or switch to alternative monotherapy 1, 2

Prophylaxis When Initiating Urate-Lowering Therapy

When starting any urate-lowering therapy, prophylaxis is mandatory:

• Low-dose colchicine 0.5-1 mg daily is first-line prophylaxis 1, 2, 4
• Low-dose NSAIDs are alternative if colchicine not tolerated or contraindicated 1, 2
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi present 4, 7
• If tophi present, continue prophylaxis for 6 months after achieving target serum urate 4, 7

Common Pitfalls to Avoid

• Do not use indomethacin preferentially—it has no efficacy advantage over other NSAIDs and may have more adverse effects 1
• Do not use high-dose colchicine regimens—they increase toxicity without improving efficacy 2, 4
• Do not treat acute gout with colchicine in patients already on prophylactic colchicine and taking strong CYP3A4 inhibitors 5
• Do not delay treatment waiting for definitive diagnosis—early treatment within 24 hours is more important than diagnostic confirmation 1, 2