What is the recommended treatment for acute gout?

Acute Gout Treatment

For acute gout, initiate treatment within 24 hours 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

First-Line Treatment Selection

The choice among the three equally effective first-line agents depends on patient-specific contraindications:

Corticosteroids (Preferred in High-Risk Patients)

• Prednisolone 30-35 mg daily for 3-5 days is the preferred first-line option in patients with renal disease, heart failure, cirrhosis, cardiovascular disease, or elderly patients 1, 3
• Corticosteroids have a superior safety profile compared to NSAIDs, with lower risk of gastrointestinal bleeding and fewer adverse events 4
• Can be administered orally, intra-articularly, or intramuscularly depending on clinical scenario 5, 2
• Monitor blood glucose in diabetic patients as corticosteroids may cause hyperglycemia 2

NSAIDs (Convenient First-Line Option)

• 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
• Avoid indomethacin preferentially as it has more adverse effects without efficacy advantage over other NSAIDs 1
• Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 2, 3
• Add gastroprotection if gastrointestinal risk factors present 2
• Adjust dose in renal impairment 5

Colchicine (Most Effective When Started Early)

• Most effective when started within 36 hours of symptom onset 1, 2
• Low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 2, 6
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects 2, 7
• High-dose colchicine regimens should not be used due to increased toxicity without improved efficacy 1
• Requires dose adjustment in renal and hepatic impairment 6
• Significant drug interactions with CYP3A4 and P-glycoprotein inhibitors require dose reduction 6

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 1, 3
• Select based on patient comorbidities and contraindications as outlined above 1

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

• Combination therapy is recommended 1, 3
• Effective combinations include:
  • Colchicine + NSAIDs 1, 3
  • Oral corticosteroids + colchicine 1, 3
  • Intra-articular steroids with any other modality 1, 3

Critical Management Principles

Timing

• Treatment must be initiated within 24 hours of symptom onset for optimal efficacy 1, 2, 3
• The most important determinant of therapeutic success is how soon treatment is initiated, not which agent is chosen 8
• Continue treatment at full dose until the gouty attack has completely resolved 1, 2

Urate-Lowering Therapy During Acute Attack

• Do not stop existing urate-lowering therapy during an acute attack 1, 2
• Do not initiate new urate-lowering therapy during an acute attack 1, 2

Managing Inadequate Response

• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours 1, 3
• Switch to another monotherapy or add a second recommended agent 1, 2, 3

Special Populations

Renal Impairment

• Corticosteroids are the safest option in renal impairment 3
• For colchicine in severe renal impairment (CrCl <30 mL/min): treatment course should be repeated no more than once every two weeks 6
• For dialysis patients: single dose of 0.6 mg colchicine, not repeated more than once every two weeks 6
• NSAIDs should be avoided or used with extreme caution 2, 3

Hepatic Impairment

• Mild to moderate hepatic impairment: monitor closely but no dose adjustment required 6
• Severe hepatic impairment: treatment course with colchicine should be repeated no more than once every two weeks 6

Patients Already on Prophylactic Colchicine

• Treatment of acute gout flares with colchicine is not recommended in patients already receiving prophylactic colchicine and CYP3A4 inhibitors 6
• Consider switching to NSAIDs or corticosteroids for acute treatment 1

Prophylaxis When Initiating Urate-Lowering Therapy

• Low-dose colchicine 0.5-1 mg daily is first-line prophylaxis when starting any urate-lowering therapy 5, 1, 2
• Alternatives include low-dose NSAIDs or low-dose prednisone if colchicine is not tolerated or contraindicated 1, 2
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi present, or 6 months after achieving target serum urate if tophi present 2, 9

Common Pitfalls to Avoid

• Do not delay treatment waiting for definitive diagnosis—early treatment within 24 hours is more important than diagnostic confirmation 1
• Do not use high-dose colchicine regimens 1
• Do not preferentially use indomethacin over other NSAIDs 1
• Do not stop urate-lowering therapy during an acute attack 1, 2
• Do not initiate new urate-lowering therapy during an acute attack 1, 2