From the Guidelines
For acute gout flares, colchicine is recommended as the first-line treatment, given as 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg on day 1), then 0.6 mg once or twice daily until symptoms resolve, due to its better tolerability and efficacy compared to indomethacin, as supported by moderate-quality evidence 1.
Comparison of Colchicine and Indomethacin
- Colchicine works by inhibiting microtubule formation and reducing neutrophil activity, while indomethacin is an NSAID that blocks prostaglandin synthesis.
- Colchicine may be preferred in patients with cardiovascular disease or renal impairment, while indomethacin might be more effective for severe pain but carries higher risks of gastrointestinal, renal, and cardiovascular side effects.
- Both medications require dose adjustment in patients with hepatic or renal impairment.
Treatment Recommendations
- Treatment should begin as soon as possible after flare onset for maximum effectiveness.
- Patients should rest the affected joint and apply ice for additional relief.
- The choice of drug(s) 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, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
Important Considerations
- Colchicine should be avoided in patients with severe renal impairment and should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin.
- Indomethacin should be used with caution in patients with gastrointestinal, renal, or cardiovascular disease.
- Patients should be fully informed and involved in decision-making concerning the use of treatments for acute gout flares.
From the Research
Comparison of Colchicine and Indomethacin for Acute Gout Flare
- Colchicine and indomethacin are both used to treat acute gout flares, but their dosing and efficacy can vary 2, 3, 4.
- Colchicine is effective for treating acute gout attacks, with low-dose colchicine demonstrating a comparable tolerability profile to placebo and a significantly lower side effect profile to high-dose colchicine 4.
- Indomethacin, an NSAID, is also effective for treating acute gout attacks, but its use may be limited by comorbidities such as chronic kidney disease and ischemic heart disease 2, 3.
- A study comparing intramuscular triamcinolone acetonide to oral indomethacin found no clinically relevant differences between the two treatments for acute gout 5.
- The optimal dosing for colchicine and indomethacin in acute gout flares is not well established, and further research is needed to determine the most effective treatment strategies 3, 6.
Efficacy and Safety of Colchicine and Indomethacin
- Colchicine and indomethacin have both been shown to be effective for treating acute gout flares, but their safety profiles can vary 2, 4, 5.
- Low-dose colchicine has been found to have a favorable tolerability profile, while high-dose colchicine can have significant side effects 4.
- Indomethacin, like other NSAIDs, can have gastrointestinal and renal side effects, particularly in patients with comorbidities 2, 3.
- Systemic corticosteroids, such as prednisolone, have also been used to treat acute gout flares, but their efficacy and safety compared to colchicine and indomethacin are not well established 5.
Treatment Guidelines and Recommendations
- The treatment of acute gout flares should be individualized based on patient comorbidities, preferences, and response to treatment 2, 3.
- Colchicine, indomethacin, and other NSAIDs are commonly used to treat acute gout flares, but their use should be guided by clinical judgment and patient-specific factors 2, 4.
- Further research is needed to establish the optimal dosing and treatment strategies for acute gout flares, including the use of colchicine and indomethacin 3, 6.