What medication should be prescribed for a 36-year-old male with suspected gout, presenting with right big toe pain and erythema at the metatarsophalangeal (MTP) joint?

From the Guidelines

For acute gout in this 36-year-old male with right big toe pain and erythema at the MTP joint, I recommend prescribing colchicine 1 mg orally as an initial dose, followed by 0.5 mg one hour later, as per the 2016 updated EULAR evidence-based recommendations for the management of gout 1. This approach is supported by the American College of Physicians, which also recommends the use of colchicine, NSAIDs, or corticosteroids for the treatment of acute gout, with a strong recommendation for low-dose colchicine 1. The patient should continue with colchicine 0.5 mg once or twice daily until symptoms resolve, typically for 7-10 days. Alternatively, an NSAID such as indomethacin 50 mg three times daily for 7-10 days could be prescribed if there are no contraindications. Key considerations for management include:

• Resting the affected joint
• Applying ice for 20 minutes several times daily
• Maintaining adequate hydration
• Avoiding triggers such as alcohol, especially beer and spirits, and sugar-sweetened drinks
• Encouraging low-fat dairy products and regular exercise Once the acute attack resolves, the patient should follow up with his primary care provider to discuss potential urate-lowering therapy and identify any underlying causes of hyperuricemia. It is essential to note that the choice of drug should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved, as outlined in the EULAR recommendations 1.

From the FDA Drug Label

The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. The medication that should be sent to the patient's pharmacy is Colchicine (PO). The dose is 1.2 mg (two tablets) at the first sign of the flare, followed by 0.6 mg (one tablet) one hour later. The frequency is a one-time dose, with the option to repeat no earlier than 3 days if necessary. The duration of treatment is until the gout flare resolves, but prophylactic therapy may be beneficial for at least the first six months of uric acid-lowering therapy. 2 2

From the Research

Medication Options for Acute Gout

The patient's symptoms suggest acute gout, and the following medication options can be considered:

• Colchicine: Low-dose colchicine may be an effective treatment for acute gout, with low-quality evidence suggesting it may improve treatment outcomes compared to placebo with little or no increased risk of adverse events 3
• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs are effective agents for the treatment of acute gout attacks, with similar efficacy to therapeutic doses of systemic corticosteroids 4
• Systemic corticosteroids: Systemic corticosteroids have similar efficacy to NSAIDs, with studies supporting oral and intramuscular use 5, 4
• Adrenocorticotropic hormone (ACTH): ACTH is suggested to be efficacious in acute gout, with exciting new research showing its potential mechanism of action 6

Dosage and Frequency

The dosage and frequency of the medication will depend on the specific medication chosen and the patient's individual needs. For example:

• Low-dose colchicine: 0.6 mg orally every hour until relief is obtained or until a maximum of 4.8 mg is reached 3
• NSAIDs: The dosage and frequency will vary depending on the specific NSAID chosen, but it is generally recommended to start with a high dose and taper down as symptoms improve 4
• Systemic corticosteroids: The dosage and frequency will vary depending on the specific corticosteroid chosen, but it is generally recommended to use the lowest effective dose for the shortest duration possible 5, 4

Duration of Treatment

The duration of treatment will depend on the severity of the patient's symptoms and the response to treatment. For example:

• Colchicine: Treatment is typically continued until symptoms resolve, which is usually within 24-48 hours 3
• NSAIDs: Treatment is typically continued until symptoms resolve, which is usually within 3-5 days 4
• Systemic corticosteroids: Treatment is typically continued for a short duration, usually 3-5 days, to avoid adverse effects 5, 4