Treatment for Acute Gout

First-Line Treatment Options

The American College of Rheumatology recommends first-line treatment for acute gout includes NSAIDs, oral colchicine, or corticosteroids, which should be initiated within 24 hours of symptom onset for optimal outcomes 1, 2, 3
Use full FDA-approved anti-inflammatory doses of NSAIDs until the gouty attack has completely resolved 1, 4
FDA-approved NSAIDs for acute gout include naproxen (500mg twice daily), indomethacin, and sulindac 4
Contraindicated in patients with renal disease, heart failure, or cirrhosis 2, 5
Colchicine is most effective when started within 36 hours of symptom onset, with a recommended low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over a one-hour period) 2
Low-dose colchicine regimen is as effective as higher doses with fewer gastrointestinal side effects 2
Common side effects of colchicine include diarrhea, nausea, vomiting, cramps, and abdominal pain 2, 5
Corticosteroids are considered first-line therapy in patients without contraindications due to their safety profile and low cost, with options including oral, intra-articular, and intramuscular administration 2, 3, 6

Renal function should be considered when selecting treatment, with NSAIDs and colchicine dose adjustments recommended in renal impairment 5
Cardiovascular disease should be considered when selecting treatment, with colchicine or corticosteroids recommended over NSAIDs 5
Gastrointestinal risk should be considered when selecting treatment, with NSAIDs recommended to be used with gastroprotection 5
Diabetes should be considered when selecting treatment, with corticosteroids recommended to be used with caution due to potential hyperglycemia 2

Initiate treatment within 24 hours of symptom onset for best outcomes 1, 3
Continue urate-lowering therapy (if already prescribed) during the acute attack 1, 6
For inadequate response, consider adding a second agent 1
Continue treatment at full dose until the gouty attack has completely resolved 4

Prophylaxis is strongly recommended when starting urate-lowering therapy, with options including low-dose colchicine, low-dose NSAIDs, and low-dose prednisone 1, 3, 4, 6
Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi are present, or 6 months after achieving target serum urate if tophi are present 4, 6