What is the first-line treatment for acute gout in an adult patient with no significant renal impairment or contraindications?

Treatment for Acute Gout

Oral corticosteroids (prednisone 30-35 mg daily for 5 days) should be considered first-line therapy for acute gout in patients without contraindications, as they are safer, lower cost, and equally effective as NSAIDs with fewer adverse effects. 1, 2

First-Line Treatment Options

All three major drug classes—corticosteroids, NSAIDs, and colchicine—are effective for acute gout, with high-quality evidence demonstrating no significant difference in pain reduction efficacy between these options. 2 However, the American College of Rheumatology provides Level A evidence (highest quality) supporting oral corticosteroids as the preferred initial choice due to their superior safety profile. 1, 2

Recommended Corticosteroid Regimens

For most patients with acute gout, start prednisone at 0.5 mg/kg per day (approximately 30-35 mg daily for average adults) using one of two approaches: 1

• Simple regimen: Give full dose for 5-10 days, then stop abruptly—use this for straightforward monoarticular involvement without significant comorbidities 1

• Tapered regimen: Give full dose for 2-5 days, then taper over 7-10 days before discontinuing—use this for severe attacks, polyarticular involvement, or patients at higher risk for rebound flares 1

Alternative Routes of Administration

• Intra-articular corticosteroid injection is the treatment of choice when only 1-2 large accessible joints are involved, providing targeted therapy with minimal systemic effects 1, 2, 3

• Intramuscular triamcinolone acetonide 60 mg is specifically recommended when patients are NPO (nothing by mouth) due to surgical/medical conditions or cannot tolerate oral medications 1

When Corticosteroids Are Particularly Preferred

Prednisone is explicitly preferred over NSAIDs in the following high-risk populations: 1, 2

• Severe renal impairment (eGFR <30 mL/min)—NSAIDs can exacerbate or cause acute kidney injury 1, 2
• Cardiovascular disease or heart failure—NSAIDs carry cardiovascular risks 1, 2
• Cirrhosis or hepatic impairment—NSAIDs are contraindicated 1
• Active peptic ulcer disease or history of GI bleeding 1, 2
• Patients on anticoagulation therapy 1

Alternative First-Line Options

NSAIDs

• Any full anti-inflammatory dose NSAID is effective, with naproxen, indomethacin, and sulindac having FDA approval for acute gout 2
• The most important determinant of success is how soon therapy is initiated, not which specific NSAID is chosen 4
• Moderate-certainty evidence shows NSAIDs and corticosteroids are probably equally effective for pain relief and treatment success 5

Colchicine

• Low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg on day 1), then 0.6 mg once or twice daily until attack resolves 2
• Achieves treatment success in approximately 42% of patients compared to 17% with placebo (absolute improvement of 25%) 2
• High-dose hourly regimens should be abandoned due to excessive toxicity 2

Critical Timing Considerations

Initiate pharmacologic treatment within 24 hours of acute attack onset for optimal efficacy—early treatment leads to better patient-reported outcomes and shorter attack duration. 2 Educate patients about the "pill in the pocket" approach, allowing them to self-initiate treatment at first warning symptoms without waiting for physician consultation. 1, 2

Absolute Contraindications to Corticosteroids

• Systemic fungal infections 1, 2
• Current active infection (corticosteroids cause immune suppression and can worsen infections) 1

Combination Therapy for Severe Attacks

For severe acute gout or polyarticular involvement (pain >6/10, multiple large joints), consider initial combination therapy: 1, 2

• Oral corticosteroids plus colchicine for synergistic anti-inflammatory effects 1, 2
• Intra-articular steroids for involved large joints plus oral corticosteroids 1

Monitoring Treatment Response

Define inadequate response as: 1

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

If inadequate response occurs, consider switching to combination therapy or alternative agent. 1

Critical Pitfalls to Avoid

• Do NOT interrupt ongoing urate-lowering therapy during an acute gout attack—this can prolong the flare 1
• Do NOT use high-dose prednisone (>10 mg/day) for prophylaxis during urate-lowering therapy initiation 1
• Do NOT use standard-dose colchicine without significant dose reduction in renal impairment—the risk of fatal toxicity outweighs benefits 1
• Do NOT use NSAIDs in patients with severe renal impairment (eGFR <30 mL/min)—they can cause acute kidney injury 1, 3

Special Considerations for Specific Populations

Elderly Patients

• Oral corticosteroids are the safest first-line choice given high prevalence of renal impairment, heart failure, and peptic ulcer disease 3
• If using colchicine, start at 50-100 mg on alternate days and adjust based on creatinine clearance 3

Patients with Diabetes

• Short-term corticosteroids can elevate blood glucose significantly—monitor glucose closely and adjust diabetic medications proactively 1
• Despite this concern, the 5-10 day course for acute gout is generally safe with appropriate monitoring 1

Patients with Renal Impairment

• Prednisone requires no dose adjustment for renal impairment, making it the safest option 1, 3
• Colchicine requires dose reduction and carries fatal toxicity risk in severe renal impairment 1, 2

Short-Term Adverse Effects of Corticosteroids

Common adverse effects with short-term use (5-10 days) include: 1

• Dysphoria and mood disorders
• Elevated blood glucose levels
• Fluid retention
• Minimal bone density risk with short courses

These risks are generally acceptable given the brief treatment duration and can be managed with appropriate monitoring. 1