What is the recommended symptomatic treatment for gouty arthritis?

Symptomatic Treatment of Acute Gouty Arthritis

For acute gout, initiate treatment within 24 hours using corticosteroids as first-line therapy (oral prednisone 30-35 mg daily for 3-5 days), NSAIDs at full anti-inflammatory doses, or colchicine (1.2 mg followed by 0.6 mg one hour later), with corticosteroids preferred due to superior safety profile and lower cost. 1, 2

Treatment Selection Algorithm

Timing is Critical

• Start pharmacologic therapy within 24 hours of symptom onset for optimal outcomes 3, 1, 2
• Colchicine is only effective if started within 36 hours of symptom onset 3, 2
• Patients should be educated on the "pill in the pocket" approach to self-initiate treatment at first warning symptoms without waiting for physician consultation 1, 2

First-Line Monotherapy (Mild to Moderate Disease)

For pain ≤6/10 on pain scale with 1-3 small joints or 1-2 large joints involved 1:

Corticosteroids (Preferred First-Line):

• Oral prednisone 30-35 mg daily for 3-5 days 1
• Alternative: prednisone 0.5 mg/kg per day for 5-10 days at full dose, then stop OR taper over 7-10 days 3
• Intra-articular injection for monoarticular involvement: triamcinolone acetonide 40-60 mg depending on joint size 3, 1
• Intramuscular: triamcinolone acetonide 60 mg 3

NSAIDs:

• Any NSAID at full FDA-approved anti-inflammatory dose is effective—no single NSAID is superior 1, 4
• FDA-approved options include naproxen, indomethacin, and sulindac 3, 1, 5
• Continue at full dose until complete resolution of symptoms 3, 2
• Avoid preferential use of indomethacin—it has no efficacy advantage over other NSAIDs and potentially more adverse effects 1

Colchicine:

• Loading dose: 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
• Continue 0.6 mg once or twice daily starting 12 hours after loading dose until attack resolves 2, 6
• Do not use high-dose colchicine regimens—they increase toxicity without improving efficacy 1
• Do not use for acute treatment if patient is already on prophylactic colchicine—choose NSAID or corticosteroid instead 3

Combination Therapy (Severe or Polyarticular Disease)

For pain ≥7/10 or involvement of ≥4 joints 1:

• Colchicine + NSAIDs 1
• Oral corticosteroids + colchicine 1
• Intra-articular steroids + any other modality 1

Patient-Specific Considerations

Renal Impairment

• Corticosteroids are the safest option and preferred in any degree of renal disease 1, 7
• NSAIDs are contraindicated in renal disease 1
• For ESRD patients: Intra-articular corticosteroid for 1-2 joints OR oral prednisone 30-35 mg daily for polyarticular disease 7
• Colchicine dose adjustments for renal impairment 6:
  • Mild-moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed for acute treatment, but monitor closely 6
  • Severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks 6
  • Dialysis patients: Single dose of 0.6 mg only, not to be repeated more than once every two weeks 6

Cardiovascular Disease, Heart Failure, or Cirrhosis

• Corticosteroids are preferred due to safer profile compared to NSAIDs 1
• Avoid NSAIDs in these populations 1

Elderly Patients

• Corticosteroids are preferred due to lower risk of serious adverse effects compared to NSAIDs 1

Hepatic Impairment

• Mild-moderate impairment: No dose adjustment required for NSAIDs or colchicine, but monitor closely 6
• Severe impairment: Colchicine treatment course should not be repeated more than once every two weeks 6

Critical Management Principles

Do NOT Interrupt Urate-Lowering Therapy

• Continue ongoing allopurinol or febuxostat without interruption during acute attack 3, 1, 2, 7
• Do not initiate new urate-lowering therapy during an acute attack 1, 2

Treatment Duration

• Continue therapy at full dose until complete resolution of symptoms 3, 2
• Typical duration is 5-14 days depending on agent and severity 2

Drug Interactions with Colchicine

• Patients taking strong CYP3A4 inhibitors (clarithromycin, ritonavir, atazanavir, etc.) require dose reduction 6
• Maximum daily dose of 0.6 mg (may be given as 0.3 mg twice daily) when combined with these agents 6
• Treatment of acute gout with colchicine is not recommended in patients receiving prophylactic colchicine AND CYP3A4 inhibitors 6

Prophylaxis When Initiating Urate-Lowering Therapy

• Low-dose colchicine 0.5-1 mg daily is first-line prophylaxis when starting any urate-lowering therapy 1, 2
• Alternative: low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with proton pump inhibitor where indicated 3, 1
• Second-line: low-dose prednisone (<10 mg/day) if colchicine and NSAIDs contraindicated 3, 1
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi present 3, 1, 2

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 stop urate-lowering therapy during acute attack 3, 1, 2, 7
• Do not use colchicine for acute treatment if patient already on prophylactic colchicine 3
• Do not use NSAIDs in patients with renal disease, heart failure, or cardiovascular disease 1
• Do not repeat colchicine treatment courses more frequently than every 2 weeks in severe renal impairment or dialysis patients 6