Management of Gout Pain
For acute gout pain, initiate treatment within 24 hours with first-line options: NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or corticosteroids (prednisone 30-35 mg daily for 3-5 days), with choice guided by patient comorbidities. 1, 2, 3
Immediate Treatment Algorithm
Mild to Moderate Pain (≤6/10) with Limited Joint Involvement (1-3 small joints or 1-2 large joints)
Choose monotherapy based on patient factors:
NSAIDs (preferred if no contraindications): Use any NSAID at full FDA-approved anti-inflammatory doses—no single NSAID is superior to another 1, 2, 4. FDA-approved options include naproxen, indomethacin, or sulindac 2. Continue at full dose until complete resolution 4. Avoid NSAIDs in patients with renal disease, heart failure, peptic ulcer disease, or cardiovascular disease 2, 3.
Corticosteroids (first-line for patients with NSAID contraindications): Prednisone 30-35 mg daily for 3-5 days, or 0.5 mg/kg/day for 5-10 days at full dose then stop 1, 2, 3. Corticosteroids are the safest option in renal impairment, elderly patients, and those with multiple comorbidities 2, 3.
Low-dose colchicine (most effective within 12-36 hours of onset): 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2, 3. High-dose colchicine regimens should never be used—they cause significant GI toxicity without additional benefit 1, 4, 3.
Severe Pain (≥7/10) or Polyarticular Involvement (≥4 joints)
Use combination therapy: 2, 4, 3
- Colchicine + NSAIDs
- Oral corticosteroids + colchicine
- Intra-articular corticosteroids (for 1-2 accessible joints) with any other modality 2, 4
Special Population Adjustments
Renal impairment: Corticosteroids are safest; avoid NSAIDs entirely 2, 3. For colchicine, reduce dose in moderate-to-severe CKD: with CrCl 30-50 mL/min, monitor closely; with CrCl <30 mL/min, use single 0.6 mg dose and do not repeat more than once every two weeks 5.
Diabetes: NSAIDs or colchicine preferred over corticosteroids 2.
GI risk factors: Corticosteroids or low-dose colchicine preferred over NSAIDs 2.
NPO patients: Intra-articular corticosteroid injection for 1-2 joints, or IV/IM methylprednisolone (0.5-2.0 mg/kg) for multiple joint involvement 4.
Critical Management Principles
Treatment timing is paramount: Initiate therapy within 24 hours of symptom onset for optimal efficacy—delaying beyond 24 hours significantly reduces effectiveness 1, 2, 3. Educate patients on the "pill in the pocket" approach to self-initiate treatment at first warning symptoms 1, 4, 3.
Continue established urate-lowering therapy without interruption during acute attacks 2, 4, 3. Do not start new urate-lowering therapy during an acute flare unless already planned, in which case it can be initiated during the flare with appropriate prophylaxis 1.
Adjunctive measures: Topical ice application and rest of the inflamed joint are appropriate adjuncts to pharmacologic therapy 2, 4.
Management of Inadequate Response
Consider inadequate response if there is <20% improvement in pain within 24 hours or <50% improvement after 24 hours of starting therapy 4. For inadequate response to initial monotherapy, switch to another monotherapy or add a second recommended agent 4. For severe refractory attacks, IL-1 inhibitors (anakinra or canakinumab) may be considered, though these remain off-label 4, 6.
Prophylaxis When Initiating Urate-Lowering Therapy
When starting any urate-lowering therapy, mandatory anti-inflammatory prophylaxis is required: 1, 4
- First-line: Low-dose colchicine 0.5-1 mg daily 1, 4, 3
- Alternatives: Low-dose NSAIDs with gastroprotection, or low-dose prednisone 1, 4
- Duration: Continue for at least 6 months, or 3 months after achieving target serum urate if no tophi present 1, 4, 3
This prophylaxis prevents the flare-up of acute attacks that commonly occurs when initiating urate-lowering therapy 1, 7. Inadequate duration of prophylaxis leads to breakthrough flares and poor medication adherence 4.
Common Pitfalls to Avoid
Never use indomethacin preferentially—it has no efficacy advantage over other NSAIDs and potentially more adverse effects 1, 2, 3.
Avoid high-dose colchicine regimens—they increase toxicity without improving efficacy 1, 2, 4, 3.
Do not discontinue urate-lowering therapy during acute flares—this worsens long-term outcomes 2, 4, 3.
Watch for colchicine drug interactions: Major interactions requiring dose reduction or avoidance include strong CYP3A4 and P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, nelfinavir) 4, 5. In patients on these medications with renal or hepatic impairment, colchicine should not be used 5.
NSAIDs are contraindicated in any degree of renal disease, heart failure, or peptic ulcer disease 2, 3.