What is the recommended treatment for acute gout in an adult patient?

Acute Gout Treatment

For acute gout, initiate treatment within 24 hours with corticosteroids, NSAIDs, or low-dose colchicine as first-line options, with corticosteroids preferred due to their superior safety profile and lower cost. 1, 2, 3

First-Line Treatment Options

The American College of Physicians and American College of Rheumatology provide high-strength evidence supporting three equally effective first-line agents 1:

• Corticosteroids (prednisolone 30-35 mg daily for 5 days) are recommended as the preferred first-line option due to superior safety and lower cost compared to alternatives 4, 2, 3
• NSAIDs at full anti-inflammatory doses (any NSAID is acceptable; no single agent is superior) 1, 2
• Low-dose colchicine (1.2 mg at onset, followed by 0.6 mg one hour later, maximum 1.8 mg over one hour) is most effective when started within 12-36 hours of symptom onset 1, 2, 3

Treatment Selection Algorithm

Step 1: Assess Patient Comorbidities

Choose corticosteroids preferentially in patients with: 4, 2, 3

• Severe renal impairment (eGFR <30 mL/min) - NSAIDs and colchicine are contraindicated 4, 2, 3
• Cardiovascular disease or heart failure - NSAIDs carry unacceptable cardiovascular risks 4, 2
• Cirrhosis or hepatic impairment - NSAIDs are contraindicated 4
• Active peptic ulcer disease or GI bleeding history - NSAIDs pose significant bleeding risk 4, 2
• Anticoagulation therapy - NSAIDs increase bleeding risk 1, 4

Avoid corticosteroids in patients with: 4

• Active systemic fungal infections (absolute contraindication) 4
• Poorly controlled diabetes (monitor glucose closely if used) 4
• Active infection (relative contraindication due to immune suppression) 4

Step 2: Assess Attack Severity and Joint Involvement

For mild-to-moderate attacks (pain ≤6/10, involving 1-3 small joints or 1-2 large joints): 2, 3

• Use monotherapy with any first-line agent 2, 3
• Prednisolone 30-35 mg daily for 5 days (no taper needed for short course) 4, 2, 3
• Alternative: Prednisone 0.5 mg/kg/day for 5-10 days at full dose then stop, OR 2-5 days at full dose followed by 7-10 day taper 1, 4

For severe attacks (pain ≥7/10 or polyarticular involvement ≥4 joints): 2, 3

• Use combination therapy from the start 2, 3
• Effective combinations include: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other oral modality 1, 2, 3

Step 3: Consider Route of Administration

For monoarticular or oligoarticular involvement (1-2 large accessible joints): 1, 4, 3

• Intra-articular corticosteroid injection is highly effective with minimal systemic effects 1, 4, 2
• Dose varies by joint size 1, 4

For NPO patients or those unable to take oral medications: 4

• Intramuscular triamcinolone acetonide 60 mg as single injection 4
• Alternative: Intramuscular methylprednisolone 40-140 mg (0.5-2.0 mg/kg) 4

Specific Dosing Regimens

Corticosteroids (Level A Evidence)

Oral prednisolone/prednisone: 1, 4, 2, 3

• Standard dose: 30-35 mg daily for 5 days (European League Against Rheumatism recommendation) 4, 2
• Alternative: 0.5 mg/kg/day for 5-10 days at full dose then stop abruptly 1, 4
• For severe attacks or higher rebound risk: 0.5 mg/kg/day for 2-5 days, then taper over 7-10 days 1, 4
• Methylprednisolone dose pack (pre-packaged taper) is also appropriate 4

Intramuscular: 4

• Triamcinolone acetonide 60 mg as single injection (specifically recommended dose) 4
• Methylprednisolone 40-140 mg (0.5-2.0 mg/kg) 4

NSAIDs (Level A Evidence)

Any NSAID at full anti-inflammatory doses is effective: 1, 2, 3

• Naproxen (FDA-approved, Evidence A) 2
• Indomethacin (FDA-approved, Evidence A) - no superiority over other NSAIDs despite historical preference 2, 3
• Sulindac (Evidence B) 2
• Continue at full dose until complete resolution of acute attack 2

For patients with GI contraindications: 2

• Celecoxib: 800 mg once, then 400 mg on day 1, then 400 mg twice daily for one week (Evidence C) 2

Colchicine (Level A Evidence for Low-Dose)

Low-dose regimen (moderate-strength evidence shows equal efficacy to high-dose with fewer GI adverse effects): 1, 2, 5

• 1.2 mg at first sign of flare, followed by 0.6 mg one hour later 2, 3, 5
• Maximum 1.8 mg over one hour 2, 3
• Do NOT repeat for at least 3 days 5
• Most effective when started within 12-36 hours of symptom onset 2, 3

Critical drug interactions requiring dose adjustment: 2, 5

• Strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, atazanavir, indinavir, nelfinavir, saquinavir, tipranavir): Reduce to 0.6 mg × 1 dose, followed by 0.3 mg 1 hour later; do not repeat for 3 days 5
• P-glycoprotein inhibitors (cyclosporine): Similar dose reduction required 2, 5

Renal impairment adjustments: 5

• Mild-to-moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed for treatment, but monitor closely 5
• Severe impairment (CrCl <30 mL/min): Use 0.6 mg × 1 dose; do not repeat for 2 weeks 5
• Dialysis patients: Single dose of 0.6 mg; do not repeat for 2 weeks 5

Critical Management Principles

Timing is paramount: 2, 3

• Treatment must be initiated within 24 hours of symptom onset for optimal efficacy 2, 3
• Earlier treatment (within 12 hours) is associated with better outcomes 2, 3
• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms 2, 3

Do NOT interrupt ongoing urate-lowering therapy during acute attack: 4, 2, 3

• Continuing established urate-lowering therapy does not worsen acute attacks 2
• Stopping therapy may prolong recovery 4, 2

Do NOT initiate new urate-lowering therapy during acute attack: 2, 3

• Wait until acute attack completely resolves before starting allopurinol or febuxostat 2, 3

Adjunctive Non-Pharmacologic Measures

• Topical ice application to affected joint 2, 3
• Rest of inflamed joint 2

Management of Inadequate Response

Define inadequate response as: 4, 2

• <20% improvement in pain within 24 hours, OR 4, 2
• <50% improvement at ≥24 hours after initiating therapy 4, 2

For inadequate response to monotherapy: 2

• Switch to another first-line monotherapy agent, OR 2
• Add a second recommended agent (combination therapy) 2

For severe refractory attacks: 2

• Consider IL-1 inhibitors (anakinra or canakinumab) as last resort, though these remain off-label 2

Common Pitfalls to Avoid

• Do NOT use high-dose colchicine regimens (hourly dosing until diarrhea) - they cause significant GI toxicity with no additional benefit compared to low-dose regimens 1, 2, 3
• Do NOT preferentially use indomethacin - it has no efficacy advantage over other NSAIDs and may have more adverse effects 3
• Do NOT delay treatment waiting for definitive diagnosis - early treatment within 24 hours is more important than diagnostic confirmation 3
• Do NOT use NSAIDs in patients with any degree of renal disease - corticosteroids are the safest option 4, 3
• Do NOT use standard-dose colchicine without dose reduction in renal impairment - risk of fatal toxicity outweighs benefits 4, 5
• Do NOT treat acute gout flares with colchicine in patients already receiving prophylactic colchicine - risk of toxicity is unacceptable 5

Prophylaxis When Initiating Urate-Lowering Therapy

Once the acute attack resolves and urate-lowering therapy is planned: 2, 3

• Low-dose colchicine 0.5-1 mg daily is first-line prophylaxis 2, 3
• Low-dose NSAIDs with gastroprotection are alternative if colchicine not tolerated 2
• Low-dose prednisone (<10 mg/day) is second-line if colchicine and NSAIDs contraindicated 4, 2
• Duration: At least 6 months, or 3 months after achieving target serum urate if no tophi present 2, 3