What is the acute treatment for gout (gouty arthritis) in an inpatient setting?

From the Guidelines

For acute gout treatment in the inpatient setting, I strongly recommend corticosteroids, NSAIDs, or colchicine as first-line options, as they have been shown to be effective in reducing pain and inflammation in patients with acute gout 1. The choice of drug should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved 1. Some key points to consider when treating acute gout in the inpatient setting include:

• Corticosteroids, such as prednisone 30-40mg daily for 3-5 days, can be used as first-line therapy in patients without contraindications, as they are generally safer and a low-cost treatment option 1.
• NSAIDs, such as indomethacin 50mg three times daily or naproxen 500mg twice daily for 3-5 days, are effective alternatives, but may have adverse effects such as dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding 1.
• Colchicine, given at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, can be used as an alternative, but may have adverse effects such as gastrointestinal issues and is contraindicated in patients with renal or hepatic impairment who are using potent cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors 1.
• In severe cases or polyarticular gout, methylprednisolone 40-80mg IV daily may be appropriate, and for single joint involvement, intra-articular corticosteroid injection (triamcinolone 10-40mg depending on joint size) can provide rapid relief 1.
• Urate-lowering therapy should not be initiated during an acute attack but can be continued if the patient is already on it, and adequate hydration and pain management with acetaminophen or opioids as needed are important supportive measures 1. It is essential to consider the patient's individual needs and preferences when choosing a treatment option, and to discuss the benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks 1.

From the FDA Drug Label

Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis ILARIS is indicated for the symptomatic treatment of adult patients with gout flares in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate. PredniSONE Tablets are indicated in the following conditions: ... 2 Rheumatic Disorders ... Acute gouty arthritis

The acute treatment of gout as an inpatient can be managed with:

• Indomethacin (PO), which is effective in relieving the pain and reducing the fever, swelling, redness, and tenderness of acute gouty arthritis 2
• Prednisone (PO), which is indicated for the treatment of acute gouty arthritis 3
• Canakinumab (SQ), which is indicated for the symptomatic treatment of adult patients with gout flares in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate 4

From the Research

Acute Treatment of Gout as an Inpatient

• The treatment of acute gout in hospitalized patients typically involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids 5.
• A systematic review of the treatment of acute gout found that NSAIDs, COX-2 inhibitors, corticosteroids, colchicine, adrenocorticotropic hormone (ACTH), and canakinumab have evidence to suggest efficacy in the treatment of acute gout 6.
• Colchicine is often used to treat acute gout, and low-dose colchicine may be an effective treatment with minimal increased risk of adverse events compared to placebo 7.
• The use of combination therapy, such as NSAIDs and colchicine, is common in the treatment of acute gout, but the evidence to support this practice is limited 5.
• Adrenocorticotropic hormone (ACTH) has been shown to be effective in the treatment of acute gout, and its use is supported by some studies 6, 8.
• Corticosteroids, such as systemic corticosteroids, have similar efficacy to therapeutic doses of NSAIDs in the treatment of acute gout 6.

Treatment Options

• NSAIDs are the preferred therapy for acute gout in patients without complications, and the most important determinant of therapeutic success is how soon NSAID therapy is initiated 8.
• Colchicine, corticosteroids, and ACTH are alternative treatment options for acute gout, and the choice of treatment depends on the individual patient's needs and medical history 6, 8.
• Xanthine oxidase inhibitors (XOI) and uricosuric drugs are used to lower serum uric acid levels in patients with recurrent or severe gout, and lesinurad is a new treatment option for patients with refractory gout 9.

Considerations

• Renal failure is a common comorbidity in patients with acute gout, and the use of NSAIDs and colchicine should be cautious in these patients 5.
• The treatment of acute gout should be individualized, and comprehensive patient education and counseling are important components of the treatment plan 9.
• Regular laboratory follow-up is necessary to monitor serum uric acid levels and adjust treatment as needed 9.