What is the treatment for painful gouty arthritis?

Treatment for Painful Gouty Arthritis

For acute gouty arthritis, initiate treatment within 24 hours with NSAIDs, colchicine, or corticosteroids as first-line monotherapy for mild-to-moderate attacks, with corticosteroids being preferred in patients with renal impairment or gastrointestinal contraindications. 1, 2

Immediate Treatment Principles

• Start pharmacologic therapy within 24 hours of symptom onset for optimal pain relief and outcomes 1, 2
• Continue any established urate-lowering therapy without interruption during the acute attack—stopping it will worsen and prolong the flare 1, 3
• Educate patients to self-initiate treatment at the first sign of an attack without waiting for medical consultation 1

First-Line Treatment Selection Based on Attack Severity

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

Choose ONE of the following monotherapy options: 1, 2

NSAIDs (Level A Evidence)

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1
• FDA-approved options for acute gout: naproxen, indomethacin, or sulindac 1, 2
• No single NSAID is superior to another—indomethacin is not more effective than other NSAIDs despite traditional preference 2, 4
• Continue at full dose until complete resolution; do not taper prematurely 1
• Avoid in patients with: peptic ulcer disease, renal failure, uncontrolled hypertension, or heart failure 5

Corticosteroids (Level A-B Evidence)

• Preferred first-line option due to safety profile and low cost, especially when NSAIDs are contraindicated 2
• Oral prednisone 0.5 mg/kg/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 daily for 5 days 2
• Safest option in renal impairment compared to NSAIDs or colchicine 2
• Preferred in patients with gastrointestinal risk factors over NSAIDs 2
• Consider NSAIDs or colchicine instead in diabetic patients due to glucose effects 2

Colchicine (Level A Evidence)

• Only effective if started within 36 hours of symptom onset 1
• Low-dose regimen: 1.2 mg followed by 0.6 mg one hour later—as effective as higher doses with significantly fewer gastrointestinal side effects 2, 4
• If patient already on prophylactic colchicine, choose a different therapy (NSAID or corticosteroid) 1
• Requires dose adjustment in renal or hepatic impairment and with significant drug interactions 1, 6
• Poorly tolerated in elderly patients; best avoided in this population 5

For Severe Pain or Polyarticular Attacks:

Use combination therapy with two agents simultaneously: 1

• Colchicine + NSAIDs 1
• Oral corticosteroids + colchicine 1
• Intra-articular steroids + any other modality 1
• Do NOT combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1, 3

Special Clinical Scenarios

NPO (Nothing by Mouth) Patients:

• Intra-articular corticosteroid injection for 1-2 joint involvement (dose varies by joint size) 1
• Intramuscular or intravenous methylprednisolone 0.5-2.0 mg/kg 1
• Subcutaneous ACTH 25-40 IU with repeat doses as needed 1
• Intramuscular triamcinolone acetonide 60 mg followed by oral prednisone (no consensus on monotherapy) 1

Inadequate Response to Initial Therapy:

Define inadequate response as: <20% pain improvement within 24 hours OR <50% improvement at ≥24 hours 1

Management approach: 1

• First, reconsider the diagnosis and rule out alternative conditions
• Switch to another first-line monotherapy agent
• Add a second recommended agent as combination therapy

Refractory Cases:

IL-1 inhibitor therapy (canakinumab 150 mg subcutaneously) is FDA-approved for symptomatic treatment when NSAIDs and colchicine are contraindicated, not tolerated, or ineffective, AND repeated corticosteroid courses are inappropriate 7, 8

• Canakinumab reduced pain by 10.7 mm more than triamcinolone at 72 hours and reduced new flare risk by 62% 8
• Higher rates of infections, neutropenia, and thrombocytopenia compared to corticosteroids 8

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
• Stopping urate-lowering therapy during acute attacks worsens and prolongs the episode 2, 3
• Using colchicine after 36 hours of symptom onset renders it ineffective 1
• Using high-dose colchicine regimens causes similar efficacy but significantly more side effects than low-dose protocols 2
• Prescribing NSAIDs without considering renal function, cardiovascular risk, and gastrointestinal history in elderly patients 5
• Combining NSAIDs with systemic corticosteroids increases gastrointestinal bleeding risk 3