From the Guidelines
The treatment of acute gout should focus on rapidly reducing inflammation and pain, with first-line therapy including corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine, as recommended by the American College of Physicians 1. The choice of medication depends on patient comorbidities, with NSAIDs avoided in those with renal impairment or gastrointestinal issues, and corticosteroids used cautiously in diabetics.
- Key considerations for treatment include:
- Initiating treatment as soon as possible after symptom onset to achieve faster resolution of the attack
- Using low-dose colchicine when colchicine is chosen for treatment, as recommended by the American College of Physicians 1
- Avoiding the initiation of long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks, as recommended by the American College of Physicians 1
- Discussing benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks, as recommended by the American College of Physicians 1
- Additional recommendations from the European League Against Rheumatism (EULAR) include:
- Treating acute flares of gout as early as possible, with fully informed patients self-medicating at the first warning symptoms 1
- Using colchicine, NSAIDs, or oral corticosteroids as first-line options for treating acute gout, with certain combinations employed for severe or refractory attacks 1
- Providing prophylaxis against flares, with colchicine or NSAIDs at low dosage, if not contraindicated, for at least 6 months after initiating urate-lowering therapy 1
From the FDA Drug Label
Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: Acute gouty arthritis
- Treatment of acute gout:
- Note: Allopurinol is used to lower serum uric acid to normal or near-normal levels and to prevent acute gouty attacks, but it is not typically used to treat acute gouty arthritis 4
From the Research
Treatment Options for Acute Gout
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout, with evidence suggesting they are effective in reducing pain and inflammation 5, 6, 7, 8.
- Colchicine is also widely used, but its use is limited by toxicity, particularly gastrointestinal adverse effects 5, 7.
- Corticosteroids are a reasonable choice for patients who cannot tolerate NSAIDs or colchicine, or who have a history of intolerance to these drugs 5, 7.
- Interleukin-1 (IL-1) inhibitors, such as canakinumab, may be effective for treating acute gout attacks that are refractory to standard therapies 7.
Considerations for Treatment
- The choice of treatment for acute gout depends on the balance between efficacy and potential adverse effects in a particular patient 5.
- Comorbidities, such as chronic kidney disease, hypertension, and gastrointestinal bleeding, should be taken into account when selecting a treatment 5, 6, 9.
- Pharmacokinetic properties, such as rapid absorption and short half-life, should be considered when selecting an NSAID for treatment of gout 5.
Emerging Therapies
- New emerging therapies, such as uricosuric agents and probenecid, are being developed for the treatment of gout 6.
- Personalization of treatment is increasing, with adjustments made based on comorbidities, patient preference, and other factors 6.
Urate-Lowering Therapy
- Urate-lowering therapies, such as allopurinol and febuxostat, are used to prevent flare-ups of gout, particularly in patients with chronic kidney disease, two or more flare-ups per year, or other indications 6, 9.
- Febuxostat is associated with an increase in all-cause and cardiovascular mortality, and is not routinely recommended 9.