First-Line Treatment for Acute Gout
For acute gout, choose corticosteroids, NSAIDs, or colchicine as first-line therapy, with corticosteroids preferred in patients without contraindications due to superior safety profile and lower cost. 1
Treatment Selection Algorithm
Corticosteroids (Preferred First-Line)
- Prednisolone 30-35 mg daily for 5 days is the preferred initial treatment due to fewer adverse effects compared to NSAIDs and lower cost than colchicine 1
- High-quality evidence demonstrates equivalent pain reduction to NSAIDs with significantly fewer gastrointestinal adverse events 1, 2
- Contraindications: systemic fungal infections, uncontrolled diabetes, active infection 1, 3
NSAIDs (Alternative First-Line)
- Any full-dose NSAID is equally effective—moderate-quality evidence shows no clinically important differences between indomethacin, naproxen, or ibuprofen 1, 2
- Indomethacin dosing: 50 mg three times daily for 2-3 days, then 25 mg three times daily for 3-5 days 4
- Critical timing: initiate within 24 hours of symptom onset for optimal effectiveness 2, 3
- Contraindications: severe renal impairment (CrCl <30 mL/min), heart failure, cirrhosis, history of GI bleeding, anticoagulation therapy 1, 2, 4
Colchicine (Alternative First-Line)
- Low-dose regimen only: 1.2 mg followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 5
- Must be initiated within 36 hours of symptom onset to be effective 2, 3, 5
- High-quality evidence shows low-dose colchicine is as effective as high-dose with significantly fewer gastrointestinal adverse effects 1
- Contraindications: severe renal or hepatic impairment, concurrent use of strong CYP3A4 or P-glycoprotein inhibitors 1, 5
- More expensive than NSAIDs or corticosteroids 1
Critical Decision Points
Choose corticosteroids when:
- Patient has renal impairment, cardiovascular disease, heart failure, cirrhosis, peptic ulcer disease, or is on anticoagulation 3, 4
- No contraindications to steroids exist 1
Choose NSAIDs when:
- Patient presents within 24 hours of symptom onset and has no renal, cardiac, or GI contraindications 2, 3
- Corticosteroids are contraindicated 1
Choose colchicine when:
- Patient presents within 36 hours of symptom onset 2, 3, 5
- Both NSAIDs and corticosteroids are contraindicated 1
- Cost is not a limiting factor 1
Common Pitfalls to Avoid
- Delaying treatment beyond 24 hours significantly reduces NSAID effectiveness 2, 3
- Using high-dose colchicine (hourly dosing)—this increases adverse effects without improving efficacy 1
- Stopping ongoing urate-lowering therapy during an acute attack—continue all chronic medications 2, 3
- Initiating urate-lowering therapy during an acute attack—wait until the flare resolves 1, 4
- Continuing high-dose indomethacin beyond 2-3 days increases adverse effects without additional benefit 4
Prophylaxis Considerations
- Do not initiate long-term urate-lowering therapy after a first gout attack or with infrequent attacks 1
- For patients with recurrent gout (≥2 episodes per year), discuss urate-lowering therapy after the acute attack resolves with concurrent prophylaxis using colchicine 0.6 mg once or twice daily for at least 6 months 1, 3