What is the recommended acute and long‑term management for a patient with a suspected acute gout attack?

Management of Suspected Acute Gout Attack

For a suspected acute gout attack, initiate pharmacologic therapy within 24 hours using NSAIDs, corticosteroids, or colchicine as first-line monotherapy for mild-to-moderate attacks, and continue any established urate-lowering therapy without interruption. 1, 2

Acute Attack Management

Immediate Treatment Principles

• Start treatment within 24 hours of symptom onset for optimal effectiveness, as delayed treatment significantly reduces therapeutic response 1, 3, 4
• Do not stop established urate-lowering therapy during an acute attack, as discontinuation can worsen and prolong the flare 1, 3, 4
• Educate patients to self-initiate treatment at the first signs of an attack without waiting for physician consultation 1, 3

First-Line Treatment Selection Based on Attack Severity

For mild-to-moderate pain (≤6/10 on pain scale) with 1-3 small joints or 1-2 large joints involved:

Choose one of the following monotherapy options 1, 2:

NSAIDs (Full Anti-inflammatory Doses)

• Naproxen: FDA-approved for acute gout at full anti-inflammatory dosing 1, 2, 5
• Indomethacin or sulindac: Also FDA-approved options, though indomethacin has no proven superiority over other NSAIDs 2, 5
• Use full FDA-approved anti-inflammatory/analgesic doses, not reduced dosing 1, 2, 3
• Avoid in patients with: heart failure, active peptic ulcer disease, significant renal disease, or recent gastrointestinal bleeding 3, 6

Corticosteroids

• Oral prednisone 0.5 mg/kg/day for 5-10 days (either full dose then stop, or 2-5 days full dose followed by 7-10 day taper) 2
• Alternative: Prednisolone 35 mg daily for 5 days 2
• Intra-articular corticosteroid injection for 1-2 affected joints (dose depends on joint size) 1, 2, 3
• Preferred in patients with: renal impairment, gastrointestinal risk factors, or contraindications to NSAIDs/colchicine 2, 6
• Use caution in: diabetic patients (NSAIDs or colchicine may be preferred) 2

Colchicine (Low-Dose Regimen)

• 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg) 2, 3, 4
• This low-dose regimen is equally effective as higher doses with significantly fewer gastrointestinal adverse effects 2, 4
• Most effective when started within 36 hours of symptom onset 4
• Dose adjustment required: Halve doses in moderate renal impairment; avoid in severe renal insufficiency or combined hepatic-renal insufficiency 6
• Critical drug interaction monitoring required, particularly with CYP3A4 inhibitors and P-glycoprotein inhibitors 4

For severe pain (≥7/10) or polyarticular involvement (≥4 joints or >1 large joint):

• Use combination therapy with two of the above agents 1
• Appropriate combinations include 1:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids + any other modality
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1, 4

Management of Inadequate Response

Define inadequate response as: <20% pain improvement within 24 hours OR <50% improvement ≥24 hours after initiating therapy 1

If inadequate response occurs 1:

• Reconsider the diagnosis and evaluate for alternative conditions (e.g., septic arthritis)
• Switch to another first-line monotherapy agent, OR
• Add a second recommended agent from the options above
• Consider biologic IL-1 inhibitors (anakinra 100 mg subcutaneously daily for 3 days, or canakinumab 150 mg subcutaneously) for severe refractory attacks, though risk-benefit ratio remains uncertain and FDA approval is lacking 1

Special Population: NPO (Nothing by Mouth) Patients

For hospitalized patients unable to take oral medications 1:

• Intra-articular corticosteroid injection for 1-2 affected joints (first choice) 1
• Intravenous or intramuscular methylprednisolone 0.5-2.0 mg/kg initial dose 1
• Subcutaneous ACTH 25-40 IU initial dose, with repeat doses as clinically indicated 1

Long-Term Management and Prophylaxis

Indications for Urate-Lowering Therapy (ULT)

Initiate ULT in patients with 3, 7, 8:

• ≥2 acute gout attacks per year
• Presence of tophi
• Chronic gouty arthropathy
• Radiographic changes of gout
• Chronic kidney disease
• Urolithiasis

Do NOT initiate ULT in patients with single or infrequent attacks (<2 per year) 2

Anti-inflammatory Prophylaxis During ULT Initiation

Mandatory prophylaxis is required when starting or titrating urate-lowering therapy, as ULT initiation triggers acute flares due to urate crystal remodeling 1, 3

First-line prophylaxis options 1, 3:

• Low-dose colchicine: 0.5-0.6 mg once or twice daily (with appropriate dose adjustment for renal impairment and drug interactions) 1, 3
• Low-dose NSAIDs: With gastroprotection if indicated 1, 3

Duration of prophylaxis 3:

• Continue for at least 6 months, OR
• 3 months after achieving target serum urate (<6 mg/dL) in patients without tophi, OR
• 6 months after achieving target serum urate in patients whose tophi have resolved

Urate-Lowering Therapy Selection

First-line ULT agents 3, 9:

• Allopurinol: Start at ≤100 mg/day and titrate upward every 2-5 weeks to reach target serum urate 3, 10
  • Average maintenance dose: 200-300 mg/day for mild gout; 400-600 mg/day for moderately severe tophaceous gout 10
  • Maximum dose: 800 mg/day 10
  • Consider HLA-B*5801 testing before initiation in high-risk populations (Koreans with CKD, Han Chinese, Thai) due to severe cutaneous adverse reaction risk 3, 8
• Febuxostat: Alternative xanthine oxidase inhibitor, though associated with increased all-cause and cardiovascular mortality (not routinely recommended as first choice) 7

Alternative agents 3, 9:

• Uricosuric agents (probenecid): For patients who cannot tolerate xanthine oxidase inhibitors, or in allopurinol-allergic patients with normal renal function and no urolithiasis history 3, 11

Target serum urate levels 3, 8:

• <6 mg/dL for most patients
• <5 mg/dL for patients with tophi (for prompt crystal dissolution)

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours dramatically reduces effectiveness 3, 4
• Using high-dose colchicine regimens (hourly dosing) causes severe gastrointestinal toxicity without additional benefit over low-dose regimens 2, 4
• Stopping ULT during acute attacks worsens and prolongs flares 3, 4
• Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 3, 4
• Ignoring colchicine drug interactions can result in serious toxicity, particularly with CYP3A4 and P-glycoprotein inhibitors 4
• Prescribing NSAIDs without considering comorbidities (renal disease, heart failure, GI bleeding history) increases adverse event risk 3, 6

Adjunctive Non-Pharmacologic Measures

• Topical ice application to affected joints during acute attacks 3
• Weight loss for obese patients 3, 9
• Dietary modifications: Avoid alcoholic beverages (especially beer), high-fructose corn syrup beverages, and purine-rich foods (organ meats, shellfish) 3, 9, 8
• Encourage consumption of vegetables and low-fat/nonfat dairy products 9
• Maintain adequate hydration: Fluid intake sufficient to yield ≥2 liters daily urinary output 10