What is the recommended treatment for a patient with gouty arthritis?

Treatment of Gouty Arthritis

For acute gouty arthritis, initiate treatment within 24 hours with NSAIDs (such as indomethacin 50 mg three times daily or naproxen at full dose), low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 0.5 mg/kg/day), selecting based on contraindications and severity of joint involvement. 1, 2

Acute Attack Management

First-Line Monotherapy Options

NSAIDs are the preferred initial treatment for most patients with acute gout:

• Start indomethacin 50 mg three times daily for 2-3 days, then reduce to 25 mg three times daily for 3-5 days until symptoms resolve 3
• Alternatively, use naproxen, sulindac, or other NSAIDs at full anti-inflammatory doses 4, 1
• Continue at full dose until the attack completely resolves 4
• Critical contraindications: severe renal impairment (creatinine clearance <30 mL/min), active GI bleeding, heart failure, or cirrhosis 3, 5

Low-dose colchicine is equally effective with fewer side effects than high-dose regimens:

• Administer 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg) 1, 3
• Must be started within 36 hours of symptom onset for optimal efficacy 4, 1
• Dose adjustments required: reduce dose by 50% in moderate renal impairment; avoid in severe renal insufficiency (creatinine clearance <10 mL/min) or combined hepatic-renal disease 4, 6
• If patient is already on prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid) 4

Oral corticosteroids are particularly useful when NSAIDs and colchicine are contraindicated:

• Prednisone 0.5 mg/kg per day (typically 30-35 mg daily) for 5-10 days at full dose, then stop or taper over 7-10 days 4, 1
• Provides similar efficacy to indomethacin with fewer adverse events 3

Intra-articular corticosteroid injection is highly effective for single joint involvement, with dose varying by joint size 1

Combination Therapy Indications

For severe presentations, use combination therapy:

• Severe pain or polyarticular involvement (≥4 joints) warrants combining two agents 1
• Attacks involving 1-3 small joints or 1-2 large joints can be managed with monotherapy 1
• Never combine NSAIDs with systemic corticosteroids due to increased GI toxicity risk 2

Treatment Timing and Response Assessment

• Initiate treatment within 24 hours of symptom onset—delaying beyond this significantly reduces effectiveness 1, 2, 7
• Inadequate response is defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours 4, 1
• If inadequate response occurs, switch to alternative agent or add second agent 4

Long-Term Management with Urate-Lowering Therapy (ULT)

Indications for ULT

Start urate-lowering therapy in patients with:

• Recurrent acute attacks (≥2 episodes per year) 3
• Tophi (palpable or on imaging) 1
• Chronic gouty arthropathy 1
• Radiographic changes of gout 1

ULT Initiation and Dosing

Allopurinol is first-line urate-lowering therapy:

• Start with 100 mg daily and increase by 100 mg weekly until serum uric acid <6 mg/dL is achieved 8
• Average maintenance dose is 200-300 mg/day for mild gout, 400-600 mg/day for moderately severe tophaceous gout 8
• Maximum dose is 800 mg daily 8
• Dose reduction required in renal impairment: 200 mg/day with creatinine clearance 10-20 mL/min; ≤100 mg/day with creatinine clearance <10 mL/min 8, 5

Target serum urate level: <6 mg/dL for all patients 1

Critical ULT Management Principles

• Do NOT interrupt ongoing ULT during an acute attack—discontinuing worsens and prolongs the attack 1, 2
• Do NOT initiate new ULT during an acute attack—wait until the attack resolves 3

Mandatory Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis must be provided when starting or adjusting ULT to prevent acute flares 1, 2:

First-line prophylaxis options:

• Low-dose colchicine 0.6 mg once or twice daily 4, 1
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with proton pump inhibitor where indicated 4, 1

Second-line option (if colchicine and NSAIDs contraindicated):

• Low-dose prednisone <10 mg/day 4, 1

Duration of prophylaxis:

• Minimum 6 months for all patients 4, 1
• OR 3 months after achieving target serum urate if no tophi present 4, 1
• OR 6 months after achieving target serum urate if tophi are present 4, 1

Non-Pharmacologic Measures

• Apply topical ice to affected joint during acute attacks 1
• Recommend weight loss for obese patients 1
• Avoid alcoholic beverages (especially beer) and high-fructose corn syrup-sweetened drinks 1, 9
• Limit purine-rich foods (organ meats, shellfish) 9
• Encourage consumption of vegetables and low-fat dairy products 9
• Maintain fluid intake sufficient for daily urinary output ≥2 liters 8

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours dramatically reduces treatment effectiveness 1, 2, 7
• Stopping ULT during acute attacks worsens outcomes and prolongs the attack 1, 2
• Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 1, 2
• Continuing high-dose indomethacin beyond 2-3 days increases adverse effects without additional benefit 3
• Using NSAIDs in high-risk patients with heart failure, peptic ulcer disease, significant renal disease, or cirrhosis 1, 3
• Inadequate colchicine dose adjustment in renal impairment leads to toxicity 4, 6, 5