What is the recommended treatment, including dosage and duration, for a patient with acute gout, considering factors such as impaired renal function and potential interactions with other medications?

Acute Gout Treatment: Dosage and Duration

First-Line Treatment Options

For acute gout, initiate treatment within 24 hours of symptom onset with NSAIDs, colchicine, or corticosteroids—all are equally effective first-line options, with selection based on renal function, gastrointestinal risk, and cardiovascular comorbidities. 1, 2

Colchicine Dosing

Acute Attack Regimen:

• 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over one hour) 2, 3, 4
• After 12 hours, continue 0.6 mg once or twice daily until attack resolves (typically a few days) 2, 3
• Critical timing: Must start within 36 hours of symptom onset—effectiveness drops dramatically beyond this window 3, 5

Renal Impairment Adjustments:

• Mild-moderate impairment (CrCl 30-80 mL/min): Use standard dosing with close monitoring 3, 4
• Severe impairment (CrCl <30 mL/min): Avoid colchicine—use corticosteroids instead 2, 3, 4
• Dialysis patients: Single dose of 0.6 mg only, repeat no sooner than 2 weeks 4

Absolute Contraindications:

• Concurrent use with strong CYP3A4 inhibitors (clarithromycin, ketoconazole) or P-glycoprotein inhibitors (cyclosporine) 3, 4
• Combined renal and hepatic impairment with these drug interactions 3, 4

NSAID Dosing

Use full FDA-approved anti-inflammatory doses until complete attack resolution 1, 3:

• Naproxen, indomethacin, or sulindac are FDA-approved options 3
• No single NSAID is superior to others 3
• Continue at full dose throughout the attack rather than early dose reduction 1, 3

Contraindications:

• Severe renal impairment (eGFR <30 mL/min)—NSAIDs can cause acute kidney injury 2
• Active or recent GI bleeding 3
• Heart failure, cirrhosis, or anticoagulation therapy 2, 3

Corticosteroid Dosing

Oral Prednisone:

• 0.5 mg/kg per day (approximately 30-35 mg daily for average adults) 1, 2
• Duration: Two options:
  • 5-10 days at full dose, then stop abruptly 1, 2
  • 2-5 days at full dose, then taper over 7-10 days (preferred for severe attacks or polyarticular involvement) 1, 2

Alternative Routes:

• Intramuscular triamcinolone acetonide 60 mg as single injection, followed by oral prednisone 1, 2
• Intra-articular injection for 1-2 large joints (dose varies by joint size) 1, 2
• IV methylprednisolone 0.5-2.0 mg/kg (40-140 mg) for NPO patients or those unable to take oral medications 2

Advantages in Specific Populations:

• Safest first-line option in severe renal impairment—no dose adjustment required 2
• Preferred over NSAIDs in cardiovascular disease, heart failure, cirrhosis, or peptic ulcer disease 2

Contraindications:

• Systemic fungal infections (absolute) 2
• Active uncontrolled infection 2, 5
• Uncontrolled diabetes (relative—monitor glucose closely) 2

Combination Therapy for Severe Attacks

For severe acute gout with polyarticular involvement or multiple large joints, use initial combination therapy 1, 3:

• Colchicine + NSAIDs 1, 3
• Oral corticosteroids + colchicine 1, 3
• Intra-articular steroids + any oral modality 1, 3

Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1, 3

Treatment Algorithm for Delayed Presentation

For attacks presenting >36 hours after onset (e.g., 1 week old):

• Corticosteroids are the most appropriate choice—colchicine window has passed and NSAID efficacy diminishes with delayed treatment 5
• Use tapered prednisone approach: full dose 2-5 days, then taper 7-10 days 5

Prophylaxis During Urate-Lowering Therapy

Initiate prophylaxis with or just prior to starting urate-lowering therapy 1:

First-line options:

• Low-dose colchicine 0.6 mg once or twice daily 1, 2
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with proton pump inhibitor where indicated 1

Second-line (if colchicine and NSAIDs contraindicated):

• Low-dose prednisone <10 mg/day 1, 2

Duration:

• At least 6 months, OR 1, 2
• 3 months after achieving target serum urate (no tophi present) 1, 2
• 6 months after achieving target serum urate (tophi present) 1, 2

Critical Pitfalls to Avoid

• Never delay treatment—initiate within 24 hours of symptom onset for optimal efficacy 1, 3
• Do not use colchicine beyond 36 hours of symptom onset 3, 5
• Do not interrupt ongoing urate-lowering therapy during an acute attack 2
• Avoid high-dose prednisone (>10 mg/day) for prophylaxis 1, 2
• Never use standard-dose colchicine without dose reduction in renal impairment 2
• Do not combine colchicine with CYP3A4/P-glycoprotein inhibitors in patients with renal or hepatic impairment—risk of fatal toxicity 3, 4