Gout Treatment

For acute gout attacks, initiate treatment within 24 hours using NSAIDs, oral corticosteroids, or low-dose colchicine as equally appropriate first-line monotherapy options, with selection based on patient comorbidities and contraindications. 1

Acute Gout Attack Management

Treatment Initiation and General Principles

Start pharmacologic therapy within 24 hours of symptom onset to optimize pain relief and functional recovery 1
Continue established urate-lowering therapy (ULT) without interruption during acute attacks—do not stop allopurinol or febuxostat when a flare occurs 1
Educate patients to self-initiate treatment at first warning symptoms without waiting for physician consultation 1

First-Line Monotherapy Options (Mild-Moderate Attacks: 1-3 Small Joints or 1-2 Large Joints)

NSAIDs:

Use full FDA-approved anti-inflammatory doses (naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily) 1
Continue at full dose until the attack completely resolves 1
Avoid in patients with chronic kidney disease (CrCl <30 mL/min), congestive heart failure, active peptic ulcer disease, or cirrhosis 1, 2
Add proton pump inhibitor for gastroprotection in high-risk patients 1

Oral Corticosteroids:

Prednisone 0.5 mg/kg per day (typically 30-35 mg daily) for 5-10 days at full dose, then stop OR taper over 7-10 days 1, 2, 3
Alternative: methylprednisolone dose pack 1
Avoid in patients with uncontrolled diabetes, active infection, or high infection risk 2, 3
Particularly useful when NSAIDs and colchicine are contraindicated 1, 2

Low-Dose Colchicine:

1.2 mg followed by 0.6 mg one hour later (total 1.8 mg in first hour), then no additional colchicine for at least 12 hours 1, 2, 3
Most effective when started within 12 hours of symptom onset; can be used up to 36 hours 1, 2
For patients already on prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid) 1
Adjust dose for renal impairment: In severe renal disease (CrCl <30 mL/min) or dialysis patients, reduce to single 0.6 mg dose and do not repeat for 2 weeks 4
Adjust for drug interactions: Reduce dose with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, diltiazem, verapamil) 1, 4

Intra-articular Corticosteroid Injection:

Highly effective for single joint involvement with dose depending on joint size 1, 2
Can be combined with oral therapies 1

Combination Therapy (Severe/Polyarticular Attacks: ≥4 Joints or Severe Pain ≥7/10)

Appropriate combination options include: 1

Colchicine plus NSAIDs at full doses
Oral corticosteroids plus colchicine
Intra-articular corticosteroids with any other oral modality

Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1

NPO (Nil Per Os) Patients

For 1-2 affected joints: Intra-articular corticosteroid injection (dose varies by joint size) 1
For multiple joints: Intravenous or intramuscular methylprednisolone 0.5-2.0 mg/kg OR subcutaneous ACTH 25-40 IU with repeat doses as needed 1

Inadequate Response Management

Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours 1, 3
Switch to another first-line monotherapy OR add a second appropriate agent 1

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT Initiation

Start ULT in patients with: 2, 3

Recurrent acute gout attacks (≥2 per year)
Tophi on physical examination
Chronic gouty arthropathy
Radiographic changes of gout
History of urolithiasis

Do not initiate ULT after a first gout attack or in patients with infrequent attacks 5

ULT Medication Options

Xanthine Oxidase Inhibitors (First-Line):

Allopurinol: Start at ≤100 mg/day (50 mg/day if CrCl <30 mL/min), titrate every 2-5 weeks to achieve target serum urate <6 mg/dL 2, 5
Febuxostat: Alternative for allopurinol-intolerant patients 1, 5

Uricosuric Agents (Alternative):

Probenecid or benzbromarone for patients with normal renal function and no history of urolithiasis 1, 5

Target Serum Urate Level

Maintain serum urate <6 mg/dL (357 μmol/L) to achieve dissolution of monosodium urate crystals 1, 2, 3

Anti-Inflammatory Prophylaxis During ULT Initiation

Mandatory Prophylaxis

Initiate prophylaxis with or just before starting ULT to prevent acute flares 1, 2

First-Line Prophylaxis Options

Low-Dose Colchicine (Preferred):

0.6 mg once or twice daily (0.5 mg outside US) 1, 2
Adjust for renal impairment: 0.3 mg daily for severe renal disease (CrCl <30 mL/min); 0.3 mg twice weekly for dialysis patients 4
Adjust for drug interactions with CYP3A4/P-glycoprotein inhibitors 1, 4

Low-Dose NSAIDs (Alternative):

Naproxen 250 mg twice daily with proton pump inhibitor if gastroprotection indicated 1, 2

Low-Dose Prednisone (Second-Line):

<10 mg/day for patients with contraindications to both colchicine and NSAIDs 1, 3
Monitor carefully for corticosteroid-related adverse effects with prolonged use 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 2

At least 6 months duration, OR
3 months after achieving target serum urate (<6 mg/dL) in patients without tophi, OR
6 months after achieving target serum urate in patients with tophi (after tophus resolution)

Non-Pharmacologic Measures

Dietary and Lifestyle Modifications

Weight loss for obese patients 1, 2, 5
Avoid alcoholic beverages, especially beer and spirits 1, 5, 6
Avoid beverages sweetened with high-fructose corn syrup 5, 6
Reduce intake of purine-rich foods (organ meats, shellfish) 1, 5, 6
Encourage consumption of vegetables and low-fat or nonfat dairy products 5, 6

Adjunctive Acute Treatment

Topical ice application to inflamed joint as adjunctive measure during acute attacks 1, 3, 5
Rest of the affected joint 7

Medication Adjustments

Discontinue thiazide and loop diuretics if possible, as they increase uric acid levels 6
Consider losartan for hypertension (increases urinary uric acid excretion) 5, 6
Consider fenofibrate for hyperlipidemia (reduces serum uric acid) 5

Critical Pitfalls and Caveats

Common Treatment Errors

Delaying treatment beyond 24 hours significantly reduces effectiveness of all acute therapies 1, 5
Stopping ULT during acute attacks worsens outcomes and prolongs disease course 1
Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 1, 5
Using high-dose colchicine regimens (>1.8 mg in first 12 hours) causes severe gastrointestinal toxicity without additional benefit 1, 2, 5

Drug-Specific Warnings

Colchicine:

Fatal toxicity can occur with drug interactions—particularly with clarithromycin, cyclosporine, and other strong CYP3A4/P-glycoprotein inhibitors 1, 5, 4
Clearance reduced by 75% in end-stage renal disease 4