What is the initial treatment for a patient with gout?

Initial Treatment for Acute Gout

For a patient presenting with acute gout, initiate treatment immediately with oral NSAIDs, corticosteroids, or colchicine as first-line therapy, with selection based on comorbidities and time since symptom onset. 1, 2

First-Line Treatment Options

The American College of Rheumatology strongly recommends three equally effective first-line agents for acute gout flares 1:

NSAIDs (First-Line Option)

• Administer full anti-inflammatory doses immediately: naproxen 500 mg twice daily or indomethacin 50 mg three times daily 2, 3
• Continue until complete symptom resolution 2, 3
• Add a proton pump inhibitor if GI risk factors are present 2
• Avoid NSAIDs in patients with: severe renal impairment (eGFR <30 mL/min), heart failure, cirrhosis, active GI bleeding, or recent cardiovascular events 2, 4

Corticosteroids (First-Line Option)

• Oral prednisone 0.5 mg/kg per day (approximately 30-35 mg daily) for 5-10 days at full dose, then stop abruptly 1, 4, 3
• Alternative regimen: 2-5 days at full dose followed by 7-10 day taper 1, 4
• For monoarticular involvement of 1-2 large joints: intra-articular corticosteroid injection (triamcinolone acetonide 40 mg for large joints, 20 mg for smaller joints) 2, 4
• Corticosteroids are the safest first-line option in patients with renal impairment, heart failure, or multiple comorbidities 2, 4
• For patients unable to take oral medications: intramuscular triamcinolone acetonide 60 mg or IV methylprednisolone 0.5-2.0 mg/kg 1, 4

Colchicine (First-Line Option)

• Only effective when started within 12 hours of symptom onset 2, 5
• FDA-approved dosing: 1.2 mg immediately, followed by 0.6 mg one hour later 1, 5
• Do not repeat the loading dose for at least 3 days 2
• Avoid in severe renal impairment (CrCl <30 mL/min) or combined hepatic-renal insufficiency 5, 6
• Reduce dose by 50% in moderate renal impairment 5, 6

Treatment Selection Algorithm

Step 1: Assess timing

• If >12 hours since symptom onset, do not use colchicine as monotherapy 2

Step 2: Assess renal function

• Severe renal impairment (eGFR <30 mL/min): Use corticosteroids (no dose adjustment needed); avoid NSAIDs and colchicine 2, 4
• Moderate renal impairment (eGFR 30-50 mL/min): Corticosteroids preferred; if using colchicine, reduce dose by 50% 5
• Normal renal function: Any first-line agent appropriate 1

Step 3: Assess cardiovascular and GI risk

• Heart failure, recent MI, or cardiovascular disease: Use corticosteroids; avoid NSAIDs 2, 4
• Active peptic ulcer disease or recent GI bleeding: Use corticosteroids; avoid NSAIDs 2, 4
• On anticoagulation: Corticosteroids preferred 4

Step 4: Assess joint involvement

• Monoarticular or oligoarticular (1-2 large joints): Consider intra-articular corticosteroid injection for rapid relief with minimal systemic effects 2, 4
• Polyarticular (≥4 joints) or severe pain: Consider combination therapy (see below) 2, 3

Combination Therapy for Severe Attacks

For severe pain or polyarticular involvement affecting multiple large joints, use combination therapy with full doses of two agents simultaneously 1, 2:

Acceptable combinations 1, 2:

• Colchicine + NSAIDs
• Oral corticosteroids + colchicine
• Intra-articular corticosteroids + any other modality

Never combine NSAIDs with systemic corticosteroids due to synergistic GI toxicity risk 2

Critical Timing Considerations

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 2, 3
• Earlier treatment results in better response regardless of agent chosen 2
• The most important determinant of success is how soon therapy is initiated, not which specific agent is chosen 7

Management of Ongoing Urate-Lowering Therapy

• Do not initiate urate-lowering therapy during an acute attack in the emergency department 2
• Do not stop urate-lowering therapy if the patient is already taking it 2, 3
• Interrupting ongoing urate-lowering therapy during acute attacks worsens outcomes 3

Monitoring Response and Inadequate Response

Define inadequate response as 4, 3:

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

If inadequate response occurs: Consider switching to another monotherapy or adding a second agent 4

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant treatment 1, 3
• Rest the inflamed joint 7

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 3, 7
• Using colchicine after 12 hours of symptom onset (ineffective) 2
• Stopping ongoing urate-lowering therapy during acute attacks (worsens outcomes) 2, 3
• Using NSAIDs in patients with severe renal impairment (risk of acute kidney injury) 2, 4
• Combining NSAIDs with systemic corticosteroids (synergistic GI toxicity) 2
• Using high-dose colchicine regimens (no additional benefit, more adverse effects) 5