What is the best treatment for acute gout?

Best Treatment for Acute Gout

For acute gout, initiate treatment within 24 hours of symptom onset with NSAIDs, oral corticosteroids, or low-dose colchicine as first-line monotherapy options—all are equally effective, and the choice depends on patient-specific contraindications rather than superiority of one agent over another. 1, 2

First-Line Treatment Options

All three first-line agents have equivalent efficacy for acute gout attacks, supported by high-quality guideline evidence:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until complete resolution of the attack 1, 2
• FDA-approved options include naproxen 500 mg twice daily, indomethacin, and sulindac 1, 2, 3
• COX-2 inhibitors (etoricoxib 120 mg daily or celecoxib 800 mg loading dose, then 400 mg twice daily) are alternatives for patients with GI contraindications 1
• Avoid in patients with renal disease (CrCl <30 mL/min), heart failure, cirrhosis, or active peptic ulcer disease 1, 4

Oral Corticosteroids

• Prednisolone 30-35 mg daily for 5 days is as effective as NSAIDs with fewer adverse effects 1, 4, 5
• Particularly useful when NSAIDs and colchicine are contraindicated 1, 2
• Caution in diabetic patients due to hyperglycemia risk; monitor blood glucose closely 2
• Safer than NSAIDs in renal impairment 4, 5

Low-Dose Colchicine

• FDA-approved regimen: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 6
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects (23% vs 77% diarrhea rate) 1, 2
• Most effective when started within 12-36 hours of symptom onset 2, 5
• Requires dose adjustment with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir)—reduce to 0.6 mg × 1 dose, then 0.3 mg one hour later 6
• Contraindicated with concurrent use of strong CYP3A4 inhibitors in renal or hepatic impairment 6

Treatment Algorithm Based on Clinical Presentation

Mild-to-Moderate Pain (≤6/10 on pain scale) with 1-3 small joints or 1-2 large joints:

• Initiate monotherapy with any of the three first-line agents 1, 2
• Selection based on contraindications, not efficacy differences 1

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

• Use combination therapy from the start 1, 4, 5
• Effective combinations include:
  • Colchicine + NSAID 1, 4
  • Oral corticosteroid + colchicine 1, 4
  • Intra-articular corticosteroid + any oral agent 1, 4

Single Joint Involvement:

• Intra-articular corticosteroid injection is highly effective and avoids systemic side effects 1, 2, 5
• Particularly useful in patients with multiple contraindications to systemic therapy 4, 5

Critical Management Principles

• Initiate treatment within 24 hours of symptom onset—delayed treatment significantly reduces effectiveness 1, 2, 5
• Continue established urate-lowering therapy (allopurinol, febuxostat) without interruption during acute attacks 1, 2, 5
• Continue anti-inflammatory therapy at full dose until complete resolution of the attack, not just improvement 1, 2
• Provide patients with "pill-in-pocket" instructions to self-initiate treatment at first warning symptoms without waiting for physician contact 1, 5

Management of Inadequate Response

Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours of therapy 4, 5

If inadequate response occurs:

• Switch to a different monotherapy agent, OR
• Add a second first-line agent as combination therapy 4, 5

Special Population Considerations

Renal Impairment (CrCl <30 mL/min):

• Corticosteroids are the safest option 4, 5
• Avoid NSAIDs entirely 1, 4
• Reduce colchicine dose: 0.6 mg × 1 dose only, do not repeat for at least 3 days 6

Cardiovascular Disease:

• Prefer colchicine or corticosteroids over NSAIDs 2
• NSAIDs increase cardiovascular event risk 1

Gastrointestinal Risk (history of ulcers or bleeding):

• Use COX-2 inhibitors or corticosteroids 1, 2
• If using non-selective NSAIDs, mandatory gastroprotection with proton pump inhibitor 1, 2

NPO (Nil Per Os) Patients:

• Intra-articular injection for 1-2 affected joints 5
• IV/IM methylprednisolone 0.5-2.0 mg/kg for polyarticular involvement 5

Common Pitfalls to Avoid

• Never use high-dose colchicine regimens (0.5 mg every 2 hours)—they cause severe GI toxicity with no additional benefit 1, 5
• Never stop urate-lowering therapy during an acute attack—this worsens and prolongs the flare 1, 2, 5
• Never delay treatment beyond 24 hours waiting for definitive crystal confirmation—early empiric treatment is more important 1, 2
• Never use colchicine at standard doses with strong CYP3A4 inhibitors without dose reduction—fatal toxicity has been reported 6
• Avoid NSAIDs in elderly patients with any degree of renal impairment 1

Prophylaxis When Initiating Urate-Lowering Therapy

Mandatory anti-inflammatory prophylaxis is required when starting allopurinol or febuxostat to prevent treatment-induced flares 2, 4, 5

Options include:

• Low-dose colchicine 0.6 mg once or twice daily 2, 5, 6
• Low-dose NSAID with gastroprotection 2, 5
• Low-dose prednisone 5-10 mg daily 2, 5

Duration: Continue for at least 6 months, or 3 months after achieving target serum urate <6 mg/dL if no tophi present 2, 5