What is the recommended treatment for acute gout?

Treatment for Acute Gout

Initiate treatment within 24 hours of symptom onset with NSAIDs, colchicine, or corticosteroids—all are equally effective first-line options, with selection based on patient comorbidities rather than drug superiority. 1, 2, 3

First-Line Treatment Options

All three first-line agents have equivalent efficacy when started early, so choose based on contraindications and patient-specific factors:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1
• FDA-approved options: naproxen 500mg twice daily, indomethacin, or sulindac 1, 3
• Contraindicated in renal disease (any degree), heart failure, cirrhosis, or significant cardiovascular disease 1, 3
• Use gastroprotection if gastrointestinal risk factors present 1
• No single NSAID is superior to another—avoid preferential use of indomethacin as it offers no efficacy advantage but potentially more adverse effects 3

Colchicine

• Dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 4
• Most effective when started within 12-36 hours of symptom onset 1, 3
• Low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 2
• Common side effects: diarrhea, nausea, vomiting, abdominal cramping 1
• Dose adjustments required:
  • Severe renal impairment (CrCl <30): treatment course repeated no more than once every 2 weeks 4
  • Dialysis patients: single 0.6 mg dose only, not repeated more than once every 2 weeks 4
  • Strong CYP3A4 inhibitors: reduce to 0.6 mg × 1 dose, then 0.3 mg 1 hour later, not repeated for 3 days 4

Corticosteroids

• Considered first-line due to superior safety profile and low cost, particularly in patients with contraindications to NSAIDs or colchicine 1, 2, 3
• Prednisolone 30-35 mg daily for 3-5 days is the recommended regimen 2, 3
• Options include oral, intra-articular, or intramuscular administration 1
• Preferred in elderly patients, renal disease, heart failure, cirrhosis, or cardiovascular disease 3
• Use with caution in diabetes due to potential hyperglycemia 1

Severity-Based Treatment Algorithm

Mild to Moderate Pain (≤6/10) with 1-3 Small Joints or 1-2 Large Joints

• Monotherapy with any first-line agent is appropriate 3

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

• Combination therapy is recommended 3
• Effective combinations:
  • Colchicine + NSAIDs 3
  • Oral corticosteroids + colchicine 3
  • Intra-articular steroids with any other modality 3

Critical Management Principles

• Treatment within 24 hours of symptom onset is more important than waiting for diagnostic confirmation—early treatment is the most important determinant of therapeutic success 1, 2, 3
• Continue treatment at full dose until the gouty attack has completely resolved 1
• Continue existing urate-lowering therapy during the acute attack—do not stop it 1, 2, 3
• Do not initiate new urate-lowering therapy during an acute attack 3
• For inadequate response to monotherapy, add a second agent 1
• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms 3

Prophylaxis When Starting Urate-Lowering Therapy

• Strongly recommended when initiating any urate-lowering therapy to prevent flares 1, 2
• First-line: low-dose colchicine 0.5-1 mg daily (or 0.6 mg once or twice daily, maximum 1.2 mg/day) 2, 3
• Alternative: low-dose NSAIDs if colchicine not tolerated or contraindicated 2, 3
• Duration: Continue for at least 6 months, or 3 months after achieving target serum urate if no tophi present, or 6 months after achieving target if tophi present 1, 2

Common Pitfalls to Avoid

• Do not use high-dose colchicine regimens—they increase toxicity without improving efficacy 2, 3
• Do not discontinue urate-lowering therapy during acute flares 2, 3
• Do not delay treatment waiting for definitive diagnosis—early treatment trumps diagnostic certainty 3
• Do not use inadequate duration of prophylaxis when starting urate-lowering therapy 2
• Avoid treating colchicine-maintained patients with full-dose colchicine for acute flares if on strong CYP3A4 inhibitors 4