What is the recommended initial treatment for acute gouty arthritis?

Treatment of Acute Gouty Arthritis

For acute gout, initiate treatment within 24 hours using NSAIDs, colchicine, or corticosteroids at full anti-inflammatory doses, with the choice based on comorbidities and contraindications rather than superiority of one agent over another. 1, 2

Timing is Critical

• Start pharmacologic therapy within 24 hours of symptom onset for optimal outcomes 3, 1, 2
• Colchicine is only effective if started within 36 hours of symptom onset 3, 1
• Do not interrupt ongoing urate-lowering therapy (allopurinol, febuxostat) during an acute attack 3, 1, 2

First-Line Treatment Options

All three first-line agents are equally effective for mild-to-moderate attacks, so selection should be based on patient-specific contraindications 1, 2:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until complete resolution of symptoms 3, 1, 2
• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 2, 4, 5
• Indomethacin 50 mg three times daily until pain is tolerable, then rapidly reduce to complete cessation 4
• Naproxen 500 mg twice daily is equally effective with potentially fewer side effects than indomethacin 5, 6
• Continue at full dose until the attack completely resolves, typically 5-14 days 1
• Avoid NSAIDs in patients with renal impairment, gastrointestinal risk factors, or cardiovascular disease 2

Colchicine

• Loading dose of 1.2 mg followed by 0.6 mg one hour later 3, 1, 2
• Then continue 0.6 mg once or twice daily starting 12 hours after loading dose until attack resolves 1
• Low-dose colchicine (1.8 mg total over 1 hour) is as effective as higher doses with significantly fewer gastrointestinal adverse effects 2, 7
• If patient is already on prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid) 3
• Avoid or adjust dose in patients with renal impairment (CrCl <30 mL/min) and those on CYP3A4 or P-glycoprotein inhibitors 3

Corticosteroids

• Oral prednisone 35 mg daily for 5 days has been successfully used and is equally effective as naproxen 2, 6
• Alternative dosing: prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 2
• Corticosteroids are the preferred first-line option in patients with renal impairment, ESRD, or contraindications to NSAIDs and colchicine 2, 8
• For monoarticular or oligoarticular involvement (1-2 joints), intra-articular corticosteroid injection (triamcinolone acetonide 40 mg for large joints) is highly effective 8
• Use caution in patients with diabetes, as corticosteroids may worsen glycemic control 2

Treatment Algorithm Based on Attack Severity

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

• Monotherapy with any first-line agent (NSAID, colchicine, or corticosteroid) is appropriate 1, 2
• Select based on patient comorbidities and prior response 1

Severe Pain (>6/10) or Polyarticular Involvement (≥3 joints)

• Combination therapy with two agents at full doses is recommended 1, 2
• Effective combinations include:
  • Colchicine + NSAIDs 1, 2
  • Oral corticosteroids + colchicine 1, 2
  • Intra-articular steroids + any other modality 2

Special Population Considerations

End-Stage Renal Disease (ESRD)

• Corticosteroids are the preferred first-line treatment 8
• For 1-2 affected joints: intra-articular corticosteroid injection (triamcinolone acetonide 40 mg for large joints like the knee) 8
• For polyarticular disease (≥3 joints): oral prednisone 30-35 mg daily for 3-5 days 8
• Avoid NSAIDs and use colchicine with extreme caution or not at all 8

Renal Impairment (non-ESRD)

• Corticosteroids are generally safer than NSAIDs or colchicine 2
• If colchicine is used, dose adjustment is required 3

Gastrointestinal Risk Factors

• Corticosteroids or low-dose colchicine are preferred over NSAIDs 2
• If NSAIDs are necessary, COX-2 selective inhibitors have significantly fewer gastrointestinal adverse events (38% vs 60% total adverse events) compared to non-selective NSAIDs 9

Diabetes

• NSAIDs or colchicine may be preferred over corticosteroids to avoid hyperglycemia 2

Critical Management Principles

• Continue established urate-lowering therapy without interruption during an acute attack 3, 1, 2, 8
• Educate patients to self-initiate treatment at the first sign of an acute attack without waiting for physician consultation 1, 2
• Continue treatment at full dose until complete resolution of symptoms, which typically takes 5-14 days depending on the agent and severity 1
• Monitor for contraindications such as uncontrolled diabetes, active infection, or recent gastrointestinal bleeding before prescribing corticosteroids 8

Common Pitfalls to Avoid

• Do not delay treatment beyond 24 hours, as efficacy decreases significantly with delayed initiation 3, 1, 2
• Do not stop urate-lowering therapy during an acute attack, as this can prolong the attack and worsen outcomes 3, 1, 2
• Do not use colchicine if symptoms have been present for more than 36 hours, as it becomes ineffective 3, 1
• Do not underdose anti-inflammatory agents—use full FDA-approved doses until complete resolution 3, 1, 2
• Do not combine NSAIDs with aspirin or other NSAIDs, as this increases adverse events without improving efficacy 5