Treatment of Acute Gout Attack in Adults Without Significant Comorbidities
For an adult with no significant past medical history experiencing an acute gout attack, initiate treatment within 24 hours with either an NSAID at full anti-inflammatory doses, oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days), or low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), and do not start long-term urate-lowering therapy after this first attack. 1, 2
Immediate Management of the Acute Attack
First-Line Treatment Options (Choose One)
The choice among these three equally effective options depends on patient preference and any contraindications:
NSAIDs at full anti-inflammatory doses are highly effective when started promptly 1, 2. Any NSAID works equally well—naproxen, indomethacin, and ibuprofen are all appropriate choices, with no evidence that indomethacin is superior despite its traditional use 1. Continue the NSAID at full dose until the attack completely resolves 1, 2.
Oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days) are as effective as NSAIDs with fewer adverse effects 1, 2. This option is particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2.
Low-dose colchicine (1.2 mg at onset, followed by 0.6 mg one hour later, maximum 1.8 mg over one hour) is equally effective as high-dose regimens but with significantly fewer gastrointestinal side effects 1, 3. Colchicine is most effective when started within 12 hours of symptom onset 2.
Critical Timing Consideration
Treatment must be initiated within 24 hours of symptom onset for optimal outcomes—delaying beyond this window substantially reduces effectiveness 1, 2, 4. Educate the patient to self-initiate treatment at the first warning symptoms using a "pill in the pocket" approach 2, 4.
Adjunctive Measures
- Topical ice application to the affected joint provides additional symptomatic relief 2, 4
- Rest of the inflamed joint is beneficial 5
What NOT to Do After a First Attack
Do not initiate long-term urate-lowering therapy (allopurinol, febuxostat) after a first gout attack or in patients with infrequent attacks (<2 per year). 1, 2 The benefits of long-term urate-lowering therapy in patients with a single or infrequent gout attacks have not been established, and urate-lowering therapy is unnecessary when the patient would have no or infrequent recurrences 1.
Important Contraindications and Caveats
NSAID Contraindications
Avoid NSAIDs in patients with:
- Renal disease, heart failure, or cirrhosis 1
- History of gastrointestinal bleeding or peptic ulcer disease 2, 6
- Patients receiving anticoagulant therapy 6
Colchicine Contraindications and Dose Adjustments
- Absolutely contraindicated in patients with severe renal or hepatic impairment who are using potent CYP3A4 inhibitors (clarithromycin, ketoconazole) or P-glycoprotein inhibitors 1, 3
- Reduce dose by half in patients with moderate renal impairment 6
- For patients on strong CYP3A4 inhibitors, reduce colchicine dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, with no repeat dosing for at least 3 days 3
Corticosteroid Contraindications
- Contraindicated in patients with systemic fungal infections 1
- Use caution in patients with diabetes (may elevate blood glucose) 1
Common Pitfalls to Avoid
Using high-dose colchicine regimens (1.2 mg followed by 0.6 mg hourly for 6 hours) causes significant gastrointestinal toxicity with no additional benefit compared to low-dose regimens 1, 2, 4
Delaying treatment beyond 24 hours substantially reduces effectiveness of all agents 1, 2, 4
Starting allopurinol during an acute attack can worsen and prolong the flare 1
Prescribing indomethacin specifically based on outdated tradition—all NSAIDs at full anti-inflammatory doses are equally effective 1
When to Consider Urate-Lowering Therapy in the Future
Revisit the decision to start urate-lowering therapy only if the patient develops:
- Recurrent attacks (≥2 episodes per year) 1, 2
- Tophi (visible or palpable urate deposits) 1, 2
- Chronic kidney disease 1
- Urolithiasis 1
- Radiographic changes of gout 1, 2
At that point, shared decision-making with the patient is warranted to review the benefits, harms, costs, and individual preferences before initiating long-term therapy 1.