What is the recommended pain relief for an acute gouty attack?

Pain Relief for Acute Gouty Attack

For acute gout, initiate treatment within 24 hours with NSAIDs, corticosteroids, or colchicine as first-line options, with corticosteroids preferred in most patients due to superior safety profile and lower cost. 1, 2

First-Line Treatment Options

All three first-line agents have comparable efficacy for pain relief, but selection should be guided by patient comorbidities and contraindications:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 3
• FDA-approved options include:
  • Indomethacin 50 mg three times daily until pain is tolerable, then rapidly reduce to cessation 4
  • Naproxen at full anti-inflammatory doses 5
  • Sulindac at approved doses 3
• No single NSAID is superior to another; indomethacin has no efficacy advantage despite traditional preference 1, 2
• Pain relief typically begins within 2-4 hours, with tenderness and heat subsiding in 24-36 hours 4
• Avoid in patients with renal impairment, heart failure, peptic ulcer disease, or cardiovascular disease 2, 6

Corticosteroids (Preferred First-Line)

• Oral prednisone 0.5 mg/kg per day (or prednisolone 30-35 mg daily) for 5-10 days at full dose, then stop 3, 1
• Alternative: 2-5 days at full dose followed by 7-10 day taper 3, 1
• Safest option in patients with renal disease, elderly patients, or those with contraindications to NSAIDs/colchicine 1, 2
• For single joint involvement: intra-articular corticosteroid injection (dose varies by joint size) 3, 6
• For NPO patients with multiple joints: IV/IM methylprednisolone 0.5-2.0 mg/kg 6
• Lower risk of gastrointestinal bleeding, indigestion, nausea, and vomiting compared to NSAIDs 7

Colchicine

• Only effective if started within 36 hours of symptom onset 3
• Dosing: 1.2 mg loading dose, followed by 0.6 mg one hour later 3, 1
• Can continue with 0.6 mg once or twice daily 12 hours later until attack resolves 3
• Low-dose regimen is as effective as high-dose with significantly fewer gastrointestinal side effects 1, 6
• Requires dose adjustment in moderate to severe renal or hepatic impairment 3
• Avoid with strong P-glycoprotein or CYP3A4 inhibitors (cyclosporine, clarithromycin) 6

Treatment Algorithm Based on Severity

Mild to Moderate Pain (≤6/10) with Limited Joint Involvement (1-3 small joints or 1-2 large joints)

• Monotherapy with any first-line agent is appropriate 1, 2
• Choose based on patient comorbidities and contraindications

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

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

Critical Management Principles

• Treatment must be initiated within 24 hours of symptom onset for optimal efficacy 3, 1
• Continue established urate-lowering therapy without interruption during acute attack 3, 1
• Do not initiate new urate-lowering therapy during an acute attack 2
• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms 2, 6

Adjunctive Measures

• Topical ice application to the affected joint 1, 8
• Rest of the inflamed joint 8

Management of Inadequate Response

• Inadequate response defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours 3
• Switch to another monotherapy or add a second recommended agent 6
• For severe refractory attacks: consider IL-1 inhibitors (canakinumab) off-label 3, 9

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 6
• Do not use high-dose colchicine regimens - they increase toxicity without improving efficacy 1, 2, 6
• Do not preferentially use indomethacin - it has no efficacy advantage and potentially more adverse effects 2
• Do not discontinue urate-lowering therapy during acute flares 1, 6
• Screen for drug interactions with colchicine before prescribing 6