What is the best medication for a patient with acute gout pain and no contraindications such as kidney disease, gastrointestinal bleeding, or Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) allergy?

Best Medication for Acute Gout Pain

For a patient with acute gout and no contraindications, NSAIDs (such as naproxen or indomethacin), corticosteroids, and low-dose colchicine are all equally effective first-line options, but NSAIDs or corticosteroids are preferred over colchicine due to superior tolerability and cost-effectiveness. 1

First-Line Treatment Options

All three medication classes have high-quality evidence supporting their use:

• NSAIDs: High-quality evidence demonstrates NSAIDs effectively reduce pain in acute gout 1. Moderate-quality evidence from 16 RCTs shows no clinically important differences between different NSAIDs 1
• Corticosteroids: High-quality indirect evidence shows systemic corticosteroids reduce pain equivalently to NSAIDs 1. Six RCTs demonstrated no difference in time to symptom resolution or pain reduction between NSAIDs and corticosteroids 1
• Colchicine: High-quality evidence shows colchicine reduces pain in acute gout 1

Recommended Specific Regimens

NSAIDs (Preferred for Most Patients)

• Indomethacin: 50 mg three times daily for 2-3 days, then 25 mg three times daily for 3-5 days until symptoms resolve 2, 3
• Naproxen: FDA-approved for acute gout at full anti-inflammatory doses 2, 4. Clinical trials show favorable response with significant clearing of inflammatory changes within 24-48 hours 4
• Any potent NSAID at full FDA-approved anti-inflammatory/analgesic doses is appropriate 2

Corticosteroids (Equally Effective Alternative)

• Oral prednisone: 0.5 mg/kg per day (approximately 30-35 mg for average adults) for 5-10 days at full dose then stop, OR give for 2-5 days at full dose followed by 7-10 day taper 5
• Intramuscular triamcinolone acetonide: 60 mg as single injection 5
• Intra-articular injection: For involvement of 1-2 large joints, dose varies by joint size 5

Colchicine (Third Option)

• Low-dose regimen: 1.2 mg followed by 0.6 mg after 1 hour (total 1.8 mg) 1, 2
• Moderate-quality evidence shows this low-dose regimen is as effective as high-dose colchicine but with significantly fewer gastrointestinal adverse effects (23% vs 77% diarrhea rate) 1

Why NSAIDs or Corticosteroids Over Colchicine

Corticosteroids should be considered first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option compared to colchicine. 5

• NSAIDs were associated with more frequent gastrointestinal adverse events than corticosteroids in comparative trials 1
• Colchicine causes gastrointestinal adverse effects including nausea, vomiting, cramps, and pain in a substantial proportion of patients 1
• Direct comparison studies show 27% of prednisolone patients reported adverse events compared to 63% in the indomethacin group 5

Treatment Initiation Timing

• Initiate pharmacologic treatment within 24 hours of acute gout attack onset for optimal efficacy 5, 2
• Significant improvement typically occurs within 24-36 hours with NSAIDs 3
• Naproxen shows favorable response with clearing of inflammatory changes within 24-48 hours 4

Combination Therapy for Severe Attacks

For severe acute gout or polyarticular involvement:

• Consider initial combination therapy with oral corticosteroids plus colchicine 5
• Intra-articular steroids can be combined with any other oral modality 5
• Caution: Combination therapy may increase adverse effects 2

Common Pitfalls to Avoid

• Do NOT interrupt ongoing urate-lowering therapy during an acute attack 5, 2, 3
• Do NOT delay treatment beyond 24 hours of symptom onset, as this reduces effectiveness 2, 3
• Do NOT continue high-dose indomethacin beyond 2-3 days, as this increases adverse effect risk without additional benefit 3
• Do NOT use high-dose prednisone (>10 mg/day) for prophylaxis during urate-lowering therapy initiation 5

Monitoring Response

Inadequate response is defined as:

• <20% improvement in pain within 24 hours, OR
• <50% improvement at ≥24 hours after initiating therapy 5

If inadequate response occurs, consider switching to an alternative first-line agent or adding combination therapy 5