Management of Acute Gout Attack

First-Line Treatment Options

The American College of Physicians recommends corticosteroids, NSAIDs, or colchicine as first-line therapy for acute gout attacks, with treatment initiated within 24 hours of symptom onset for optimal outcomes 1, 2
Corticosteroids are considered first-line therapy in patients without contraindications due to their safety profile and low cost 2
Prednisolone 35 mg for 5 days has been successfully used to treat acute gout, according to the American College of Physicians 1
The American College of Rheumatology suggests alternative dosing for corticosteroids, including oral prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 4
NSAIDs should be used at full FDA-approved anti-inflammatory/analgesic doses, as recommended by the American College of Rheumatology 4, 6
FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac, according to the American College of Rheumatology 6
The American College of Physicians states that there is no evidence that indomethacin is more efficacious than other NSAIDs 1, 2
Colchicine is effective at low doses, with a regimen of 1.2 mg followed by 0.6 mg 1 hour later being as effective as higher doses with fewer gastrointestinal adverse effects, as recommended by the American College of Physicians 1, 7

For mild to moderate pain (≤6/10) with limited joint involvement, monotherapy with any of the first-line agents is appropriate, according to the American College of Rheumatology 4, 6
For severe pain or polyarticular involvement, combination therapy is appropriate, with effective combinations including colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality, as recommended by the American College of Rheumatology 4, 6

Initiate treatment within 24 hours of symptom onset for best results, as recommended by the American College of Rheumatology 4
Continue established urate-lowering therapy without interruption during an acute attack, according to the American College of Rheumatology 4
Educate patients to initiate treatment upon first signs of an acute attack, as recommended by the American College of Rheumatology 6
For patients with a single or infrequent gout attacks (<2 per year), long-term urate-lowering therapy is not recommended, according to the American College of Physicians 1

For patients with renal impairment, corticosteroids are generally safer than NSAIDs or colchicine, as recommended by the American College of Physicians 1, 2
For patients with diabetes, NSAIDs or colchicine may be preferred over corticosteroids, according to the American College of Physicians 1
For patients with gastrointestinal risk factors, corticosteroids or low-dose colchicine are preferred over NSAIDs, as recommended by the American College of Physicians 1, 2