What is the recommended first‑line treatment for an acute gout attack and how should it be managed thereafter?

Acute Gout: First-Line Treatment and Management

For an acute gout attack, initiate NSAIDs at full anti-inflammatory doses, oral colchicine (1.2 mg followed by 0.6 mg one hour later if started within 36 hours), or corticosteroids (prednisone 0.5 mg/kg/day) within 24 hours of symptom onset, selecting based on renal function, gastrointestinal risk, and cardiovascular comorbidities. 1, 2

Treatment Selection Algorithm

Choose your first-line agent based on the following hierarchy:

• Severe renal impairment (CrCl <30 mL/min): Use corticosteroids as first-line; avoid NSAIDs and colchicine 2, 3

• Cardiovascular disease, heart failure, cirrhosis, peptic ulcer disease, or anticoagulation: Prefer corticosteroids over NSAIDs 2, 3

• Active infection, uncontrolled diabetes, or recent GI bleeding: Avoid corticosteroids; use colchicine if renal function permits, or consider intra-articular injection for monoarticular disease 2, 3

• Patients on strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole): Colchicine is absolutely contraindicated; use NSAIDs or corticosteroids 3, 4

• Otherwise healthy patients: Any of the three options (NSAIDs, colchicine, or corticosteroids) are equally appropriate 1

NSAID Therapy

Dosing and duration:

• Use full FDA-approved anti-inflammatory doses until complete attack resolution 1, 2
• FDA-approved NSAIDs for gout include naproxen, indomethacin, and sulindac 1, 3
• Indomethacin: 50 mg three times daily for 2-3 days, then 25 mg three times daily for 3-5 days 5
• Continue at full dose throughout the attack rather than early dose reduction 1, 2

Critical timing: Initiate within 24 hours of symptom onset for optimal efficacy 1

Colchicine Therapy

Dosing regimen:

• 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg) 2, 3, 4
• This low-dose regimen is as effective as high-dose colchicine but with significantly fewer gastrointestinal side effects 2, 3
• After 12 hours, resume prophylactic dosing of 0.6 mg once or twice daily until attack resolves 2, 3, 4

Critical timing window: Colchicine is only effective if started within 36 hours of symptom onset; effectiveness drops significantly beyond this timeframe 1, 3

Dose adjustments in renal impairment:

• Mild to moderate impairment (CrCl 30-80 mL/min): Use standard dosing with close monitoring 3
• Severe impairment (CrCl <30 mL/min): Avoid colchicine entirely 2, 3

Corticosteroid Therapy

Oral corticosteroids:

• Prednisone 0.5 mg/kg/day (approximately 30-35 mg for average adults) 2, 3
• For straightforward monoarticular cases: Give full dose for 5-10 days then stop abruptly 2
• For severe attacks, polyarticular involvement, or high rebound risk: Give full dose for 2-5 days followed by 7-10 day taper 2

Alternative routes:

• Intramuscular triamcinolone acetonide 60 mg for patients unable to take oral medications 3
• Intra-articular corticosteroid injection for monoarticular or oligoarticular involvement of accessible large joints 3

Combination Therapy for Severe Attacks

For polyarticular gout or multiple large joints, use combination therapy: 1, 3

• Acceptable combinations: Colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids + any oral agent 3
• Avoid: NSAIDs + systemic corticosteroids due to synergistic gastrointestinal toxicity 1, 3

Ongoing Management During Acute Attack

Do not interrupt urate-lowering therapy (allopurinol, febuxostat) during an acute attack 1

Prophylaxis When Initiating Urate-Lowering Therapy

All patients starting or adjusting urate-lowering therapy require anti-inflammatory prophylaxis: 1, 2

• First-line: Colchicine 0.6 mg once or twice daily 1, 2, 3
• Second-line: Low-dose NSAID with proton pump inhibitor, or low-dose prednisone (<10 mg/day) 2, 3
• Duration: At least 6 months, or 3 months after achieving target uric acid without tophi 1, 2, 3

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces efficacy 1
• Starting colchicine beyond 36 hours of symptom onset is ineffective 1, 3
• Using high-dose colchicine (>1.8 mg in first hour) provides no additional benefit but substantially increases gastrointestinal toxicity 3
• Early dose reduction of NSAIDs before complete attack resolution increases risk of prolonged symptoms 1, 2
• Combining NSAIDs with systemic corticosteroids increases gastrointestinal bleeding risk 1, 3
• Prescribing colchicine to patients on strong CYP3A4 inhibitors can cause fatal toxicity 3, 4