From the Guidelines
Acute gout treatment should begin with corticosteroids, such as prednisolone at a dose of 35 mg for 5 days, as first-line therapy due to their effectiveness and lower adverse effects compared to NSAIDs. This approach is supported by the American College of Physicians guideline 1, which suggests that corticosteroids are generally safer and a low-cost treatment option. For patients with contraindications to corticosteroids, alternative options include:
- Colchicine at a loading dose of 1.2 mg followed by 0.6 mg one hour later, then 0.6 mg once or twice daily for 7-10 days, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1
- NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 5-7 days, although these may have more adverse effects and are not recommended as first-line therapy for patients with certain comorbidities
- Joint aspiration with corticosteroid injection for monoarticular gout
During an acute attack, patients should:
- Rest the affected joint
- Apply ice for 20 minutes several times daily
- Maintain adequate hydration It is essential to address the underlying cause of gout through lifestyle modifications, such as:
- Weight loss, if appropriate
- Limiting alcohol intake, especially beer and spirits
- Reducing consumption of purine-rich foods and sugar-sweetened drinks
- Encouraging low-fat dairy products and regular exercise Urate-lowering therapy, like allopurinol, should not be initiated during an acute attack, but existing therapy should be continued 1. Prompt treatment initiation is crucial for faster resolution of symptoms and prevention of joint damage from prolonged inflammation.
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. For the treatment of acute gout, the suggested dosage of indomethacin is 50 mg taken three times a day until the pain is tolerable. The dose should then be rapidly reduced to complete cessation of the drug.
- Key points:
- Dosage: 50 mg t.i.d.
- Duration: Until pain is tolerable
- Reduction: Rapidly reduce dose to complete cessation of the drug 2
From the Research
Acute Gout Treatment Options
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout, with evidence suggesting they are effective in reducing pain and inflammation 3.
- Colchicine is also an effective treatment for acute gout, with low-dose colchicine demonstrating a comparable tolerability profile to placebo and a significantly lower side effect profile to high-dose colchicine 4, 5.
- Corticosteroids, including systemic and intraarticular glucocorticoids, are effective in treating acute gout, with moderate quality evidence suggesting they are as effective as NSAIDs but safer 5.
- Interleukin-1 (IL-1) inhibitors, such as canakinumab, have been shown to be effective in treating acute gout, particularly in patients refractory to standard therapies 4, 5.
Comparison of Treatment Options
- NSAIDs and COX-2 inhibitors have similar efficacy in treating acute gout, with non-selective NSAIDs probably resulting in little to no difference in pain, swelling, and treatment success compared to COX-2 inhibitors 3.
- Systemic glucocorticoids and NSAIDs are probably equally beneficial in terms of pain relief, improvement in function, and treatment success, although NSAIDs may result in more total adverse events 3.
- Low-dose colchicine is safer than high-dose colchicine, with no difference in efficacy between the two doses 4, 5.
Treatment Guidelines
- The treatment of acute gout should be individualized, taking into account comorbidities, patient preference, and potential side effects of medications 6.
- Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating urate-lowering therapy to prevent acute gouty arthritis for a period of at least 6 months 7.