What are the treatment guidelines for acute gouty arthritis?

Treatment Guidelines for Acute Gouty Arthritis

Initiate pharmacologic therapy within 24 hours of symptom onset using NSAIDs, colchicine, or corticosteroids as first-line monotherapy for mild-to-moderate attacks, and continue treatment at full dose until complete resolution of symptoms. 1, 2

Critical Timing Principles

• Start treatment within 24 hours of acute gout attack onset for optimal patient outcomes 1, 2
• Colchicine is only effective if initiated within 36 hours of symptom onset 1, 2
• Do not stop ongoing urate-lowering therapy (allopurinol, febuxostat) during an acute attack - continue without interruption 1, 2

First-Line Treatment Options for Mild-to-Moderate Attacks

For attacks with pain ≤6/10 on a 0-10 scale involving 1-3 small joints or 1-2 large joints, choose one of the following monotherapy options 1:

NSAIDs (Evidence A)

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1, 2
• FDA-approved options include:
  • Indomethacin 50 mg three times daily until pain is tolerable, then rapidly reduce to cessation 3
  • Naproxen at full anti-inflammatory dosing 1
  • Sulindac at approved doses 1
• Continue at full dose without tapering until complete symptom resolution 1
• Common pitfall: Starting NSAIDs too late or at inadequate doses reduces efficacy 1, 4

Colchicine (Evidence A)

• Loading dose: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later 1, 2, 5
• Then continue 0.6 mg once or twice daily starting 12 hours after loading dose until attack resolves 1, 2
• If patient is already on prophylactic colchicine, give 1.2 mg followed by 0.6 mg one hour later, then resume prophylaxis dosing 12 hours later 1
• Critical caution: Adjust doses in renal impairment or with P-glycoprotein/CYP3A4 inhibitors 5
• Patients typically experience pain improvement within 12-24 hours 5

Corticosteroids (Evidence A)

• Oral prednisone 0.5 mg/kg per day for 5-10 days at full dose, then stop 1
• Alternative: 2-5 days at full dose, then taper over 7-10 days 1
• Intra-articular injection: Dose varies by joint size (can be combined with oral therapy) 1
• Intramuscular: Triamcinolone acetonide 60 mg, then oral prednisone as above 1

No single agent is ranked superior - selection should be based on comorbidities, contraindications, and prior patient response 1

Treatment for Severe or Polyarticular Attacks

For severe pain (>6/10) with polyarticular involvement or multiple large joints 1:

Use combination therapy with two agents at full doses (Evidence C) 1, 2:

• Colchicine + NSAIDs 1
• Oral corticosteroids + colchicine 1
• Intra-articular steroids with any other modality 1

Critical warning: The American College of Rheumatology did not vote on NSAIDs + systemic corticosteroids due to concerns about synergistic gastrointestinal toxicity 1

Monitoring Treatment Response

• Inadequate response is defined as: <20% improvement in pain score within 24 hours OR <50% improvement at 24 hours 1, 5
• If inadequate response occurs, add a second appropriate agent from a different therapeutic class 1, 5

Special Populations

Patients with ESRD

• Corticosteroids are preferred first-line treatment 6
• For 1-2 affected joints: intra-articular triamcinolone acetonide 40 mg for large joints 6
• For ≥3 joints: oral prednisone 30-35 mg daily for 3-5 days 6
• Avoid colchicine and NSAIDs due to safety concerns in renal failure 6

COX-2 Inhibitors

• Etoricoxib (not available in USA) has Level A evidence for efficacy 1
• Celecoxib: 800 mg once, then 400 mg on day 1, then 400 mg twice daily for one week (Evidence C) - use only in carefully selected patients with NSAID contraindications, as risk-benefit ratio remains unclear 1

Anti-Inflammatory Prophylaxis When Initiating Urate-Lowering Therapy

Start prophylaxis with or just prior to initiating urate-lowering therapy 1, 2:

First-Line Prophylaxis Options

• Low-dose colchicine 0.6 mg once or twice daily 1, 2
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with proton pump inhibitor where indicated 1

Second-Line Prophylaxis

• Low-dose prednisone or prednisolone (<10 mg/day) if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1

Duration of Prophylaxis

Continue for the greater of 1, 2:

• At least 6 months, OR
• 3 months after achieving target serum urate (if no tophi detected on physical exam), OR
• 6 months after achieving target serum urate (if one or more tophi detected on physical exam)

Patient Education and Self-Management

• Instruct patients to self-initiate treatment at the first sign of an attack without waiting for physician consultation 1, 2
• Educate on dietary and medication triggers of acute attacks 1
• Provide patients with a supply of medication to keep at home for immediate use 2

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces efficacy of all agents 1, 2, 4
• Stopping urate-lowering therapy during an acute attack - this worsens outcomes and prolongs disease course 1, 2
• Using inadequate doses of NSAIDs or corticosteroids - full anti-inflammatory doses are required 1
• Exceeding colchicine loading dose (>1.8 mg in first 12 hours) increases gastrointestinal toxicity without added benefit 1, 5
• Failing to initiate prophylaxis when starting urate-lowering therapy leads to increased flare frequency and poor adherence 7, 8