What is the recommended treatment for a patient experiencing a gout attack, considering potential contraindications such as impaired renal (kidney) function?

Treatment of Acute Gout Attack

For an acute gout attack, initiate treatment within 24 hours using first-line options of NSAIDs, colchicine, or corticosteroids, with the specific choice determined by renal function, comorbidities, and severity of attack. 1, 2

General Principles

• Start treatment immediately – preferably within 24 hours of symptom onset for optimal outcomes 1
• Continue urate-lowering therapy (ULT) without interruption during an acute attack if the patient is already on it 1
• Educate patients to self-medicate at first warning symptoms with a "medication-in-pocket" strategy 1, 2

First-Line Treatment Options (Equally Effective)

NSAIDs

• Use full anti-inflammatory doses of any potent NSAID (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 1, 2
• Add a proton pump inhibitor if gastrointestinal risk factors are present 1, 2
• Can be used with caution in moderate renal impairment (CrCl 30-50 mL/min), but avoid in severe renal impairment 1, 2
• Continue for 5-10 days at full dose then stop, or taper over 7-10 days after 2-5 days at full dose 1

Colchicine

• FDA-approved dosing: 1.2 mg immediately, followed by 0.6 mg one hour later (total 1.8 mg on day 1) 1, 3
• Only effective if started within 12-36 hours of symptom onset 1, 2
• Low-dose colchicine is strongly recommended over high-dose due to similar efficacy with fewer adverse effects 1

Critical dose adjustments for renal impairment:

• Mild-moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed for acute treatment, but monitor closely 3
• Severe impairment (CrCl <30 mL/min): Use same dose but do not repeat course more than once every 2 weeks 3
• Dialysis patients: Single dose of 0.6 mg only, not to be repeated more than once every 2 weeks 3
• Avoid completely if patient is on strong P-glycoprotein/CYP3A4 inhibitors (clarithromycin, ritonavir, ketoconazole) or has combined severe renal-hepatic impairment 2, 3

Corticosteroids

• Oral: Prednisone/prednisolone 30-35 mg daily for 3-5 days, then stop or taper over 7-10 days 1, 2
• Intramuscular: Triamcinolone acetonide 60 mg single dose 1
• Intra-articular injection: Excellent option if only 1-2 accessible joints involved, avoiding systemic exposure 2
• Safest systemic option for severe chronic kidney disease (CrCl <30 mL/min) 2
• Monitor blood glucose, mood changes, fluid retention, and infection risk 2

Algorithm for Choosing First-Line Agent

Mild-moderate attack (pain ≤6/10,1-3 small joints or 1-2 large joints):

• Normal renal function (CrCl >50): Any of the three options (NSAID, colchicine, or corticosteroid) 1
• Moderate renal impairment (CrCl 30-50): Colchicine or corticosteroids preferred; NSAIDs with caution 2, 3
• Severe renal impairment (CrCl <30): Corticosteroids are the safest choice; colchicine only as single course 2, 3
• GI contraindications/bleeding risk: Corticosteroids or colchicine (avoid NSAIDs) 1, 2
• Diabetes or psychiatric history: NSAIDs or colchicine preferred over corticosteroids 2

Severe/polyarticular attack (pain >6/10, ≥4 joints or ≥3 large joints):

• Use combination therapy: Colchicine + NSAID, or colchicine + corticosteroid, or intra-articular steroid + oral agent 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic GI toxicity 1

Second-Line Options

IL-1 Inhibitors

• Canakinumab 150 mg subcutaneously is conditionally recommended when all first-line options are contraindicated, ineffective, or poorly tolerated 1, 2
• Absolute contraindication: Active infection 2
• Major limitation: Cost and access 1

Parenteral Corticosteroids

• Strongly recommended over IL-1 inhibitors or ACTH when patient cannot take oral medications 1
• Intramuscular or intravenous options available 1

Adjunctive Measures

• Topical ice application to affected joint provides additional pain relief 1, 2
• Rest the inflamed joint during acute attack 4

Common Pitfalls to Avoid

• Do NOT stop urate-lowering therapy during an acute attack – this can prolong or worsen the flare 1
• Do NOT use colchicine for acute treatment if patient is already on prophylactic colchicine and taking CYP3A4 inhibitors 3
• Do NOT repeat colchicine treatment courses in severe renal impairment more frequently than every 2 weeks 3
• Do NOT combine NSAIDs with systemic corticosteroids due to increased GI bleeding risk 1
• Do NOT delay treatment – efficacy decreases significantly after 24-36 hours from symptom onset 1, 2