From the Guidelines
For acute gout in a 58-year-old male with left toe pain and swelling, I recommend starting with an NSAID such as indomethacin 50 mg three times daily for 3-5 days, then tapering to 25 mg three times daily for another 3-5 days until symptoms resolve, as supported by high-quality evidence from the American College of Physicians guideline 1. Alternatively, colchicine can be used with a loading dose of 1.2 mg followed by 0.6 mg one hour later, then 0.6 mg once or twice daily until symptoms improve, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. For patients with contraindications to NSAIDs or colchicine, oral prednisone 30-40 mg daily for 3-5 days with a gradual taper over 10-14 days is appropriate, as suggested by the management of acute and recurrent gout guideline from the American College of Physicians 1. The affected joint should be rested, elevated, and ice can be applied for 20 minutes several times daily. Adequate hydration is important, and the patient should avoid alcohol and purine-rich foods during the acute attack. Once the acute attack resolves, consider urate-lowering therapy such as allopurinol starting at 100 mg daily and gradually increasing to achieve a serum uric acid level below 6 mg/dL, as recommended by the EULAR guideline 1. These medications work by either reducing inflammation (NSAIDs, colchicine, steroids) or preventing uric acid crystal formation (allopurinol), which is the underlying cause of gout when uric acid crystals deposit in joints, triggering an inflammatory response. Key considerations in managing gout include:
- Starting treatment as early as possible after the onset of symptoms
- Choosing the most appropriate medication based on the patient's medical history and current condition
- Providing patient education on lifestyle modifications, such as weight loss, exercise, and dietary changes, to help prevent future gout attacks
- Monitoring serum uric acid levels and adjusting treatment as needed to achieve the target level.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) that exhibits antipyretic and analgesic properties... Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis
- Treatment options for a 58-year-old male with a history of gout and current left toe pain and swelling include:
- Indomethacin: a non-steroidal anti-inflammatory drug (NSAID) that can help relieve pain, reduce fever, swelling, redness, and tenderness of acute gouty arthritis 2
- Colchicine: may be used for prophylaxis and treatment of gout flares, however, the provided label does not directly address the treatment of acute gouty arthritis in this specific scenario 3
- Note: The provided labels do not include a direct comparison of these treatment options for this specific patient scenario.
- Key consideration: When selecting a treatment, it is essential to consider the patient's medical history, current condition, and potential interactions with other medications.
- Recommendation: Based on the provided information, indomethacin may be considered for the treatment of acute gouty arthritis in this patient, but it is crucial to consult the patient's medical history and current condition to determine the best course of treatment.
From the Research
Treatment Options for Gout
The patient's symptoms of left toe pain and swelling are consistent with a gout flare. The following treatment options are available:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Colchicine
- Oral or intramuscular corticosteroids
- IL-1 inhibitors for flare refractory to standard therapies 4, 5
Urate-Lowering Therapy
Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy:
- Allopurinol and febuxostat as initial treatments
- Uricosuric agents, such as probenecid, sulfinpyrazone, and benzbromarone, as adjuncts 4
Colchicine Dosage
Low-dose colchicine (0.6 mg/day) can adequately prevent gout flare with fewer adverse events compared with regular-dose colchicine (1.2 mg/day) 6
Pharmacokinetics Considerations
Knowledge of the pharmacokinetics of available drugs for gout management is mandatory, especially in patients with comorbid conditions such as renal failure, cardiovascular disease, and metabolic syndrome 7
Emerging Therapies
Novel uricosurics, such as verinurad and arhalofenate, are agents with future promise, and pegloticase is effective for patients with recalcitrant gout 5