Management of Acute Gouty Arthritis

Treatment of Acute Gout

The American College of Physicians recommends initiating treatment immediately with colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral corticosteroids, choosing according to patient comorbidities and contraindications 1, 2
Treatment should be started as soon as possible after symptom onset to maximize effectiveness, with patients educated to self-medicate at the first warning signs 1, 2, 3
Colchicine is preferred if initiated within the first 12 hours, with a loading dose of 1 mg followed by 0.5 mg one hour later on day 1, and a maximum of 2 mg/day 1, 2, 4
NSAIDs are effective, with no significant clinical difference between them, and should be used with a proton pump inhibitor if there is gastrointestinal risk 5, 6, 1, 2
Oral corticosteroids, such as prednisolone 30-35 mg/day for 3-5 days, are a safe alternative when colchicine and NSAIDs are contraindicated 1, 2, 3, 5

Patients should receive comprehensive education on the pathophysiology of gout, being a curable disease with appropriate treatment 1, 2, 3
Lifestyle modifications should be initiated immediately, including weight loss if overweight or obese, avoiding alcohol (especially beer and spirits), eliminating sugary drinks and foods high in fructose, reducing excessive consumption of red meat and seafood, promoting low-fat dairy products, and regular exercise 1, 7, 2

Systematic evaluation should include renal function (creatinine, creatinine clearance), cardiovascular risk factors, hypertension, diabetes, hyperlipidemia, and obesity 1, 2, 3

The American College of Physicians strongly recommends not initiating ULT after a first attack or in patients with infrequent attacks 5
However, consider initiating ULT early if the patient presents with young age (<40 years) and very high uric acid levels (>8 mg/dL), significant comorbidities, tophi, chronic gouty arthropathy, or kidney stones 1, 7, 2

If ULT is decided, it can be started during an acute attack; there is no need to wait for the attack to resolve 9, 10, 11
Prophylactic anti-inflammatory therapy is mandatory when initiating ULT, with colchicine 0.5-1 mg/day, continued for a minimum of 3-6 months 1, 9, 7, 2
Allopurinol is the first-line treatment, starting with 100 mg/day and titrating up by 100 mg every 2-4 weeks, aiming for a serum uric acid level <6 mg/dL (360 μmol/L) 1, 7, 2

Regularly monitor serum uric acid levels 1, 7, 2
Evaluate the frequency of gout attacks 4, 6
Continue anti-inflammatory prophylaxis while attacks persist, even beyond 6 months if necessary 9, 10, 11
Do not stop ULT during acute attacks once started 8