From the Guidelines
The acute management of gout should focus on rapidly reducing pain and inflammation during a flare, with first-line treatment options including corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine, as recommended by the American College of Physicians 1. The choice of treatment should be based on the presence of contraindications, the patient’s previous experience with treatments, and the number and type of joint(s) involved.
- Key treatment options include:
- NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days
- Colchicine, using a loading dose of 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until the attack resolves
- Oral corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) or intra-articular steroid injections for patients who cannot take NSAIDs or colchicine
- Additional recommendations include:
- Resting the affected joint
- Applying ice for 20 minutes several times daily
- Maintaining hydration
- Continuing any existing urate-lowering therapy during the attack
- Avoiding alcohol and purine-rich foods during flares
- Starting treatment within 24 hours of symptom onset for maximum effectiveness These medications work by inhibiting different inflammatory pathways triggered by urate crystal deposition in joints, with NSAIDs blocking prostaglandin synthesis, colchicine disrupting microtubule formation in neutrophils, and corticosteroids broadly suppressing inflammation, as supported by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
From the FDA Drug Label
Acute gouty arthritis. Suggested Dosage: Indomethacin capsules 50 mg t.i.d. until pain is tolerable. The dose should then be rapidly reduced to complete cessation of the drug. Definite relief of pain has been reported within 2 to 4 hours. Tenderness and heat usually subside in 24 to 36 hours, and swelling gradually disappears in 3 to 5 days.
The acute management of gout involves the use of indomethacin at a dose of 50 mg t.i.d. until pain is tolerable, then rapidly reducing the dose to complete cessation of the drug 2.
- Key points:
- Initial dose: 50 mg t.i.d.
- Duration: until pain is tolerable
- Reduction: rapidly reduce dose to complete cessation of the drug
- Relief: definite relief of pain within 2 to 4 hours, tenderness and heat subside in 24 to 36 hours, and swelling disappears in 3 to 5 days.
From the Research
Acute Management of Gout
The acute management of gout involves several treatment options, including:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5, 6, 7
- Glucocorticoids 3, 4, 5, 6, 7
- Colchicine 3, 4, 5, 6, 7
- Interleukin-1 (IL-1) inhibitors, such as canakinumab 4, 5, 6
- Adrenocorticotropic hormone (ACTH) 4
- Topical ice 4
- Herbal supplements 4
Treatment Efficacy and Safety
Studies have shown that:
- NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks 4
- Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs 4, 6
- Low-dose colchicine has a comparable tolerability profile to placebo and a significantly lower side effect profile to high-dose colchicine 4, 6
- IL-1β inhibitory antibody, canakinumab, is effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 4, 6
- GC, NSAID, low-dose colchicine, and canakinumab all effectively treat acute gout, but there is insufficient evidence to rank them 6
Treatment Guidelines
The treatment of acute gout attacks focuses on relieving pain and inflammation, while long-term management involves uric acid-lowering treatment to prevent future flares 3, 5, 7. Patient education and counseling on risk factors and contributors to hyperuricemia and gout can improve the likelihood of successful therapy 7.