What is the management for acute gout?

Emergency Department Management of Acute Gout

Initiate corticosteroids as first-line therapy for acute gout in the ED unless contraindicated, as they are equally effective as NSAIDs but safer and lower cost. 1, 2, 3

Immediate Treatment Approach

First-Line Monotherapy Options

Treatment must be started within 24 hours of symptom onset for optimal efficacy—early initiation is more critical than which specific agent you choose. 3

Corticosteroids (Preferred First-Line):

• Prednisolone 30-35 mg orally daily for 3-5 days is the recommended regimen 2, 3
• Alternative dosing: 0.5 mg/kg/day for 5-10 days 2
• Preferred in patients with renal disease, heart failure, cirrhosis, cardiovascular disease, or peptic ulcer disease 1, 3
• Safer profile than NSAIDs, especially in elderly patients 3

NSAIDs (Alternative First-Line):

• Use any NSAID at full anti-inflammatory dose—no single NSAID is superior 3
• FDA-approved options include naproxen, indomethacin, and sulindac 3
• Avoid in any degree of renal impairment, heart failure, or cirrhosis 1, 3
• Common pitfall: Indomethacin should NOT be used preferentially despite tradition—it has no efficacy advantage and potentially more adverse effects 3

Colchicine (Alternative First-Line):

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 1, 2, 4
• Maximum dose: 1.8 mg over one hour period 4
• Most effective when started within 12-36 hours of symptom onset 2, 3
• Critical pitfall: High-dose colchicine regimens should NOT be used—they increase toxicity without improving efficacy 3
• Low-dose regimen has significantly fewer gastrointestinal side effects compared to higher doses 1

Intra-articular Corticosteroid Injection:

• Recommended for single joint involvement 2
• Can be combined with any other modality for severe presentations 1, 3

Severity-Based Treatment Algorithm

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

• Use monotherapy with any first-line agent 1, 3

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

• Use combination therapy 1, 3
• Effective combinations include:
  • Colchicine + NSAIDs 1, 3
  • Oral corticosteroids + colchicine 1, 3
  • Intra-articular steroids with any other modality 1, 3

Inadequate Response Protocol

If <20% improvement in pain within 24 hours or <50% improvement after 24 hours of therapy, switch to another monotherapy or add a second recommended agent. 1

Special Population Considerations

Renal Impairment:

• Corticosteroids are the safest option and should be first-line 1, 2, 3
• NSAIDs are contraindicated in any degree of renal disease 3
• Colchicine requires dose adjustment based on creatinine clearance 1, 2

Hepatic Impairment:

• Colchicine dose reduction and close monitoring required 1, 2

Elderly Patients:

• Corticosteroids preferred due to lower risk of serious adverse effects compared to NSAIDs 3

Drug Interactions with Colchicine:

• If patient is on strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, atazanavir) or P-gp inhibitors, reduce colchicine dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, with dose repeated no earlier than 3 days 4
• Fatal colchicine toxicity has been reported with clarithromycin 4

Critical Management Principles for ED Discharge

Do NOT stop existing urate-lowering therapy during an acute attack 3

Do NOT initiate new urate-lowering therapy during an acute attack 3

Patient Education for Discharge:

• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms of future flares 3
• Treatment within 24 hours of symptom onset is critical for efficacy 3

Non-Pharmacologic Measures to Recommend:

• Topical ice and rest of the inflamed joint 5
• Weight loss for obese patients 1, 2
• Avoid alcoholic drinks, especially beer 1, 2
• Avoid beverages sweetened with high-fructose corn syrup 1, 2
• Limit purine-rich foods (organ meats, shellfish) 1

Follow-Up Indications

Refer for long-term urate-lowering therapy if patient has: 1, 2

• Recurrent gout flares (≥2 per year)
• Tophi
• Radiographic changes/urate arthropathy
• Renal stones