Acute Gout Management Guidelines

First‑Line Therapy

The American College of Physicians strongly recommends oral corticosteroids as the first‑line treatment for acute gout flares, based on high‑quality evidence showing comparable pain relief to NSAIDs and a superior safety profile【1】.
Corticosteroids provide equivalent pain reduction to NSAIDs, with mean improvement of approximately 44–46 mm on a 100‑mm visual analog scale at 90 hours【2】.
Corticosteroids result in significantly fewer adverse events, especially gastrointestinal complications, compared with NSAID therapy【1】.
A regimen of prednisone 35 mg once daily for 5 days (no taper required) achieves complete symptom resolution in most patients【2】.

Meloxicam is preferred over indomethacin for patients requiring an NSAID, because it offers better gastrointestinal tolerability without compromising analgesic efficacy【1】【2】.
No NSAID has demonstrated superiority for pain relief in acute gout; COX‑2 selective agents (including meloxicam) and non‑selective NSAIDs achieve similar reductions in pain, inflammation, and overall treatment success【2】 (moderate‑certainty evidence).
The historic preference for indomethacin lacks evidence support and persists mainly from tradition【2】.

Meloxicam 15 mg once daily is the recommended anti‑inflammatory dose for acute gout attacks【2】.
If an NSAID is used, indomethacin may be given 50 mg three times daily with rapid taper after pain control, but this regimen is less convenient and associated with higher adverse‑event risk【ignore ref】.

Prescribing indomethacin reflexively as “the gout drug” is outdated and not supported by comparative efficacy data【2】.
Using NSAIDs in patients with renal impairment can precipitate acute kidney injury; always assess renal function before prescribing【2】.
Stopping treatment prematurely leads to rebound flares; maintain full‑dose therapy until symptoms fully resolve【2】.
Combining NSAIDs with anticoagulants markedly increases bleeding risk; switch to corticosteroids in such cases【2】.

Short‑course corticosteroids may cause transient hyperglycemia but remain safer than NSAIDs for diabetic patients, even those with nephropathy; temporary adjustment of diabetes medications can manage the glucose rise【2】.

Corticosteroids are preferred over NSAIDs, which can exacerbate heart failure and raise cardiovascular event risk【2】.

Advancing age heightens NSAID‑related adverse‑event risk; consider lower doses, shorter durations, or preferential use of corticosteroids【ignore ref】.