Acute Gout Symptom Management
For acute gout symptoms, start with low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs, or corticosteroids (prednisone 30-35 mg daily for 5 days), with the choice depending primarily on kidney function and comorbidities. 1
Treatment Selection Algorithm
Step 1: Assess Kidney Function and Contraindications
In patients with CKD stage 3 or higher (eGFR <60 mL/min/1.73m²), corticosteroids are the safest first-line option because NSAIDs can precipitate acute kidney injury and colchicine toxicity risk increases substantially with renal impairment. 1, 2
- For severe renal impairment (eGFR <30 mL/min): Use prednisone 30-35 mg daily for 5 days—no dose adjustment needed. Avoid NSAIDs entirely and avoid standard-dose colchicine. 1, 2
- For moderate renal impairment (eGFR 30-60 mL/min): Prednisone remains preferred; if colchicine is used, reduce dose by 50%. 1, 3
- For normal renal function: All three options (colchicine, NSAIDs, corticosteroids) are appropriate. 1
Step 2: Choose Specific Medication Based on Patient Profile
Colchicine Dosing (FDA-Approved)
- Acute flare treatment: 1.2 mg (two 0.6 mg tablets) at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over one hour). 3
- Maximum dose: Do not exceed 1.8 mg over one hour period. Higher doses are not more effective and cause more gastrointestinal adverse effects. 1, 3
- Contraindications: Severe renal insufficiency, combined hepatic-renal insufficiency, concurrent use with strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir). 3, 4
NSAID Options
- Any potent NSAID is effective—the key is rapid initiation within 24 hours of symptom onset, not which specific NSAID is chosen. 1, 4
- Naproxen 500 mg twice daily or indomethacin 50 mg three times daily are commonly used regimens. 1
- Contraindications: Active peptic ulcer disease, recent GI bleeding, severe renal impairment, heart failure, cirrhosis, anticoagulation therapy. 5, 4
Corticosteroid Regimens
- Oral prednisone: 0.5 mg/kg/day (approximately 30-35 mg for average adults) for 5-10 days at full dose then stop, OR 2-5 days at full dose followed by 7-10 day taper. 1, 2
- Intra-articular injection: For monoarticular involvement of accessible large joints (knee, ankle), inject corticosteroid directly—provides targeted therapy with minimal systemic effects. 1, 2
- Intramuscular option: Triamcinolone acetonide 60 mg IM as single injection for patients unable to take oral medications. 2
Step 3: Special Considerations for This Patient
Given the history of kidney stones and hyperuricemia:
- Avoid uricosuric agents (probenecid, benzbromarone) as they increase urinary uric acid excretion and stone risk. 1
- For acute symptoms: Corticosteroids are likely the safest choice given CKD and stone history—use prednisone 30-35 mg daily for 5 days. 1, 2
- If colchicine is chosen: Ensure no drug interactions with CYP3A4 inhibitors and adjust dose for renal function. 3
Common Pitfalls to Avoid
- Do not use high-dose colchicine regimens (hourly dosing until diarrhea)—this outdated approach causes severe GI toxicity without added benefit. 1, 3
- Do not delay treatment—efficacy of all agents decreases significantly if not started within 24 hours of symptom onset. 2, 4
- Do not start or stop urate-lowering therapy during an acute flare—this can prolong or worsen the attack. 1, 2
- Do not use NSAIDs in patients with eGFR <30 mL/min—risk of acute kidney injury outweighs benefits. 1, 5
Combination Therapy for Severe Attacks
For severe polyarticular gout or inadequate response to monotherapy (defined as <20% pain improvement within 24 hours), consider combining oral corticosteroids with colchicine or adding intra-articular injection for involved large joints. 2
Long-Term Prophylaxis Consideration
Once the acute flare resolves, prophylaxis with low-dose colchicine (0.6 mg once or twice daily) should be initiated when starting urate-lowering therapy to prevent recurrent flares, continuing for at least 6 months. 1, 3