What is the management of gouty arthritis?

Management of Gouty Arthritis

Initiate pharmacologic therapy within 24 hours of acute gout attack onset with NSAIDs, corticosteroids, or colchicine as first-line options, and continue any established urate-lowering therapy without interruption during the acute attack. 1, 2

Acute Attack Treatment Algorithm

Timing is Critical

• Begin treatment within 24 hours of symptom onset for optimal outcomes 1, 2
• Colchicine is most effective when started within 36 hours of symptom onset 1, 3
• Do not interrupt ongoing urate-lowering therapy (ULT) during an acute attack - stopping ULT can worsen and prolong the attack 1, 2, 3

First-Line Treatment Selection Based on Clinical Presentation

For mild to moderate pain (≤6/10) with limited joint involvement (1-2 joints):

Choose monotherapy with one of the following 2:

NSAIDs:

• Use full FDA-approved anti-inflammatory doses 1, 2
• FDA-approved NSAIDs for acute gout: naproxen, indomethacin, sulindac 1, 2
• Continue at full dose until the attack completely resolves 1
• Avoid in patients with renal impairment - NSAIDs can exacerbate or cause acute kidney injury 2, 4

Corticosteroids (preferred in patients with renal impairment or contraindications to NSAIDs/colchicine):

• Oral 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 1
• Alternative: prednisolone 35 mg for 5 days 2
• Intra-articular injection: dose varies by joint size 1
• Intramuscular: triamcinolone acetonide 60 mg 1
• Preferred in patients with diabetes over NSAIDs or colchicine 2

Colchicine:

• Low-dose regimen: 1.2 mg followed by 0.6 mg one hour later 1, 2, 3
• This low-dose regimen is as effective as higher doses with fewer gastrointestinal adverse effects 2, 3
• If patient is already on prophylactic colchicine, choose NSAID or corticosteroid instead 1
• Requires dose adjustment in chronic kidney disease and for drug interactions 1

For severe pain (>6/10) or polyarticular involvement (≥4 joints):

Use combination therapy 2:

• Colchicine plus NSAIDs 2
• Oral corticosteroids plus colchicine 2
• Intra-articular steroids with any other modality 2

Special Population Considerations

Renal impairment:

• Corticosteroids are generally safer than NSAIDs or colchicine 2
• NSAIDs are not recommended due to risk of acute kidney injury 2, 4
• Colchicine requires dosage reduction based on level of kidney function 2, 4

Gastrointestinal risk factors:

• Corticosteroids or low-dose colchicine are preferred over NSAIDs 2
• If NSAID needed, selective COX-2 inhibitors (etoricoxib) may be considered, though they share many adverse events with NSAIDs 1

Diabetes:

• NSAIDs or colchicine may be preferred over corticosteroids 2

Anti-Inflammatory Prophylaxis During Urate-Lowering Therapy

Initiate prophylaxis with or just prior to starting ULT to prevent acute flares triggered by crystal mobilization: 1, 2, 5

First-line prophylactic options:

• Low-dose colchicine: 0.6 mg once or twice daily 1
• Low-dose NSAID therapy with proton pump inhibitor when indicated 1, 2

Duration of prophylaxis:

• Continue for at least 6 months 3, 6
• Continue if there is any clinical evidence of continuing gout disease activity and/or the serum urate target (<6 mg/dL) has not yet been achieved 1

Long-Term Urate-Lowering Therapy

Allopurinol is first-line therapy for chronic gout with tophi or recurrent attacks (≥2 per year): 2, 7, 5

• Start with low dose (100 mg daily) and increase at weekly intervals by 100 mg until serum uric acid ≤6 mg/dL is attained 5
• Maximum recommended dose: 800 mg daily 5
• Average maintenance dose: 200-300 mg/day for mild gout, 400-600 mg/day for moderately severe tophaceous gout 5
• Requires dose reduction in renal impairment: creatinine clearance 10-20 mL/min use 200 mg daily; <10 mL/min use ≤100 mg daily 5

Febuxostat is an alternative first-line option, particularly in patients with allopurinol intolerance or contraindications 7

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 3
• Stopping ULT during acute flares worsens and prolongs the attack 1, 2, 7, 3
• Using high-dose colchicine regimens causes significant gastrointestinal side effects without additional benefit 3
• Failing to provide prophylaxis when initiating ULT leads to increased flare frequency 7, 3, 5
• Combining NSAIDs with systemic corticosteroids increases risk of gastrointestinal toxicity 3
• Failing to consider drug interactions with colchicine can lead to serious toxicity 3
• Not adjusting doses in renal impairment increases risk of adverse events, particularly with colchicine and NSAIDs 2, 5, 4