What is the recommended treatment for acute gout?

Treatment for Acute Gout

For acute gout, initiate treatment within 24 hours of symptom onset with NSAIDs, colchicine, or corticosteroids as first-line monotherapy, with corticosteroids preferred in patients with renal disease, heart failure, or cardiovascular disease due to superior safety profile. 1, 2, 3

First-Line Treatment Options

All three first-line agents are equally effective for acute gout when initiated early, but selection depends on patient-specific contraindications 1, 2:

NSAIDs

• Use full FDA-approved anti-inflammatory doses until the gouty attack completely resolves 4, 1
• FDA-approved options include naproxen 500mg twice daily, indomethacin, and sulindac 1
• No single NSAID is superior to another; the most important factor is early initiation, not which specific agent is chosen 4, 3, 5
• Contraindicated in any degree of renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 2, 3
• COX-2 inhibitors (celecoxib 800mg once, then 400mg on day 1, then 400mg twice daily for one week) can be used in patients with GI contraindications to traditional NSAIDs, though risk-benefit ratio remains unclear 4

Colchicine

• Most effective when started within 36 hours of symptom onset 4, 1, 3
• Dosing: 1.2mg at first sign of flare, followed by 0.6mg one hour later (maximum 1.8mg over one hour) 1, 3, 6
• Low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 1, 7
• After initial dosing, resume prophylactic dose (0.6mg once or twice daily) 12 hours later until attack resolves 4, 6
• Do not use for treatment of acute flares in patients already on prophylactic colchicine who are also taking CYP3A4 inhibitors 6
• Requires dose adjustment in severe renal impairment (CrCl <30 mL/min): single 0.6mg dose only, not to be repeated more than once every two weeks 6
• Major drug interactions with CYP3A4 and P-glycoprotein inhibitors require dose reduction 4, 6

Corticosteroids

• Preferred first-line option in patients with renal disease, heart failure, cirrhosis, cardiovascular disease, or elderly patients 2, 3
• Prednisolone 30-35mg daily for 3-5 days is the recommended regimen 2, 3
• Equally effective as NSAIDs with superior safety profile and lower cost 2, 8
• Options include oral, intra-articular, and intramuscular administration 1
• Use with caution in diabetics due to potential hyperglycemia 1

Severity-Based Treatment Algorithm

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

• Monotherapy with any first-line agent is appropriate 2, 3
• Select based on patient comorbidities and contraindications 1, 2

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

• Combination therapy is recommended 2, 3
• Effective combinations include:
  • Colchicine + NSAIDs 2, 3
  • Oral corticosteroids + colchicine 2, 3
  • Intra-articular steroids with any other modality 2, 3

Critical Management Principles

• Treatment must be initiated within 24 hours of symptom onset for optimal efficacy—this is more important than waiting for diagnostic confirmation 1, 2, 3
• Continue treatment at full dose until the gouty attack has completely resolved 4, 1
• Do not stop existing urate-lowering therapy during an acute attack 1, 2, 3
• Do not initiate new urate-lowering therapy during an acute attack 2, 3
• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms 3

Inadequate Response Management

• Inadequate response defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours 2
• Switch to another monotherapy or add a second recommended agent 1, 2

Prophylaxis When Initiating Urate-Lowering Therapy

• Low-dose colchicine 0.5-1mg daily is first-line prophylaxis when starting any urate-lowering therapy 3, 9, 10
• Low-dose NSAIDs or low-dose prednisone are alternatives if colchicine is not tolerated or contraindicated 1, 3
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi are present 1, 9

Common Pitfalls to Avoid

• Do not preferentially use indomethacin—it has no efficacy advantage over other NSAIDs and potentially more adverse effects 3
• Do not use high-dose colchicine regimens—they increase toxicity without improving efficacy 3, 7
• Do not delay treatment waiting for definitive diagnosis—early treatment within 24 hours is more important 3
• Do not use NSAIDs in patients with any degree of renal impairment 2, 3
• Do not treat acute flares with colchicine in patients on prophylactic colchicine who have renal or hepatic impairment 6