What is the management of gouty arthritis?

Management of Gouty Arthritis

Initiate pharmacologic therapy within 24 hours of acute gout attack onset using NSAIDs, corticosteroids, or colchicine as first-line monotherapy, with treatment selection based on contraindications and severity of joint involvement. 1, 2

Acute Attack Management

Timing and General Principles

• Start treatment within 24 hours of symptom onset for optimal effectiveness—delaying beyond this window significantly reduces treatment efficacy. 1, 2, 3
• Continue established urate-lowering therapy (ULT) without interruption during an acute attack; stopping ULT worsens and prolongs the attack. 1, 2, 3
• Educate patients to self-initiate treatment at the first signs of an attack. 2

First-Line Treatment Options (Choose One Based on Contraindications)

NSAIDs:

• Use full FDA-approved anti-inflammatory/analgesic doses until the attack completely resolves. 1, 2, 3
• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac, though other NSAIDs are equally effective. 1, 2, 3
• Avoid in patients with renal impairment as NSAIDs can exacerbate or cause acute kidney injury. 2, 4

Corticosteroids (Preferred in Renal Impairment):

• 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, 2
• Alternative: Prednisolone 35 mg for 5 days. 2
• 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
• Preferred in patients with renal impairment or contraindications to NSAIDs/colchicine. 2, 4
• Use caution in diabetic patients; consider NSAIDs or colchicine instead. 2

Colchicine:

• Low-dose regimen: 1.2 mg followed by 0.6 mg one hour later (as effective as higher doses with fewer gastrointestinal side effects). 2, 3
• Most effective when started within 36 hours of symptom onset. 1, 3
• If patient is already on prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid). 1
• Requires dose adjustment in chronic kidney disease and for drug interactions—colchicine toxicity increases significantly in CKD. 1, 4
• Avoid high-dose regimens due to significant gastrointestinal toxicity without additional benefit. 3

Treatment Algorithm Based on Severity

Mild to Moderate Pain (≤6/10) with Limited Joint Involvement:

• Monotherapy with any first-line agent (NSAID, corticosteroid, or colchicine) is appropriate. 2, 3

Severe Pain or Polyarticular Involvement (≥4 joints):

• Combination therapy is appropriate: 2, 3
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality
• Avoid combining NSAIDs with systemic corticosteroids due to increased gastrointestinal toxicity risk. 3

Anti-Inflammatory Prophylaxis During ULT Initiation

When to Initiate Prophylaxis

• Start prophylaxis with or just prior to initiating urate-lowering therapy to prevent acute flares triggered by crystal mobilization. 1, 5, 6
• Continue prophylaxis for at least 6 months or until serum urate target (<6 mg/dL) is achieved and there is freedom from acute attacks for several months. 1, 3, 6

Prophylaxis Options

Low-dose Colchicine (First-Line):

• 0.6 mg once or twice daily. 1, 5
• Adjust dose in chronic kidney disease and for drug interactions. 1

Low-dose NSAIDs (Alternative First-Line):

• Use with proton pump inhibitor when gastrointestinal risk factors present. 1, 5

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

• Recommended for patients with frequent attacks (≥2 per year), tophi, or chronic gouty arthritis. 2, 5
• Not recommended for patients with single or infrequent attacks (<2 per year). 2

ULT Medications

Allopurinol (First-Line):

• Start with 100 mg daily and increase at weekly intervals by 100 mg until serum uric acid ≤6 mg/dL is achieved (maximum 800 mg/day). 6
• Target serum urate: <6 mg/dL (upper limit of normal is ~7 mg/dL for men and postmenopausal women, 6 mg/dL for premenopausal women). 6
• Dose adjustment required in renal impairment: 6
  • Creatinine clearance 10-20 mL/min: 200 mg daily
  • Creatinine clearance <10 mL/min: ≤100 mg daily
  • Creatinine clearance <3 mL/min: may need to lengthen interval between doses
• Maintain adequate hydration (≥2 liters daily urinary output) and neutral to slightly alkaline urine. 6

Febuxostat (Alternative First-Line):

• Appropriate for patients with allopurinol intolerance or contraindications. 5
• Not studied in patients with creatinine clearance <30 mL/min. 4

Critical Pitfalls to Avoid

• Never stop ULT during an acute attack—this worsens and prolongs the attack. 2, 5, 3
• Never delay treatment beyond 24 hours of symptom onset—effectiveness drops significantly. 3
• Never fail to provide prophylaxis when initiating ULT—this leads to increased flare frequency. 5, 3
• Never use high-dose colchicine regimens—they cause significant gastrointestinal side effects without additional benefit. 3
• Never ignore drug interactions with colchicine—this can lead to serious toxicity. 3
• Never combine NSAIDs with systemic corticosteroids—this increases gastrointestinal toxicity risk. 3