Management of Acute Gout

Pathophysiology and Risk Factors

Gout results from hyperuricemia leading to deposition of monosodium urate crystals in joints, triggering an intense inflammatory response that causes the characteristic acute gouty arthritis 1
Urate becomes insoluble above approximately 404 µmol/L (6.8 mg/dL), at which point crystal precipitation occurs in joint spaces, cartilage, bones, tendons, and bursas 1
The inflammatory cascade triggered by these crystals produces the acute symptoms of joint swelling, pain, and tenderness 1
Risk factors include obesity, hypertension, alcohol intake (especially beer), diuretic use, high-fructose foods/drinks, and impaired renal function 2

The American College of Physicians recommends corticosteroids as first-line therapy for acute gout in patients without contraindications because they are safer, equally effective as NSAIDs, and low-cost 1
Corticosteroids, such as prednisolone 35 mg daily for 5 days, are effective for acute gout treatment 1
NSAIDs, such as naproxen, indomethacin, and sulindac, are also effective, but may have more adverse effects, especially in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 3
Colchicine, with a low-dose regimen of 1.2 mg followed by 0.6 mg one hour later, is equally effective as higher doses with significantly fewer gastrointestinal side effects 1, 3

For mild to moderate pain (≤6/10) with limited joint involvement, monotherapy with any first-line agent is appropriate 3
For severe pain (≥7/10) or polyarticular involvement, combination therapy is recommended, with effective combinations including colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 3, 5
Prophylactic therapy with low-dose colchicine or low-dose NSAIDs is essential when initiating urate-lowering therapy to prevent acute flares 6, 4, 5

The American College of Rheumatology recommends initiating urate-lowering therapy in patients with recurrent gout flares (≥2 per year), tophi, radiographic changes, or renal stones 4, 5
Allopurinol, starting with 100 mg daily and increasing by 100 mg at weekly intervals until serum urate <6 mg/dL is achieved, is a common urate-lowering therapy 4
Febuxostat, an alternative xanthine oxidase inhibitor, is clinically equivalent to allopurinol, but has a higher cost 6

Inadequate response is considered if <20% improvement in pain within 24 hours or <50% improvement after 24 hours of therapy, and may require switching to another monotherapy or adding a second recommended agent 5
In patients with renal impairment, corticosteroids are safer than NSAIDs or colchicine, and allopurinol dose should be adjusted based on creatinine clearance 3, 4, 5
In patients with hepatic impairment, colchicine dose reduction and close monitoring are recommended 4

Weight loss for obese patients, avoidance of alcoholic drinks (especially beer), and avoidance of beverages sweetened with high-fructose corn syrup are recommended non-pharmacologic measures 2, 4, 5
Limiting purine-rich foods (organ meats, shellfish) and encouraging consumption of vegetables and low-fat dairy products are also recommended 4