Acute Gout
When treating acute gout, it is essential that healthcare professionals differentiate the treatment from chronic management. The goal of acute gout management is to quickly and safely block the intense inflammatory response elicited by deposition of urate crystals in and around joints and soft tissues.
The three first-line anti-inflammatory medications strongly recommended for treating an attack of gout are NSAIDs, colchicine, or glucocorticoids. Colchicine dosing has become more restricted during the past decade or two. The recommended initial colchicine dose for acute gout is 1.2 mg, followed by 0.6 mg 1 to 2 hours later with a cumulative dose of < 2 mg to 3 mg over 24 to 48 hours. Intravenous colchicine should not be used because of its potential serious toxicity.
Optimal management of acute gout includes:
first-line medications: colchicine, NSAIDS, glucocorticoids
colchicine: initial dose is 1.2 mg, followed by 0.6 mg 1 to 2 hours later
begin high-dose NSAIDS or glucocorticoids as soon as possible and taper quickly
does not begin ULT until acute attack has subsided
Most clinicians have more experience with NSAIDS and glucocorticoids, and their use as first-line anti-inflammatory medications for acute gout is encouraged. These medications should be started at high dose (eg, 2400 mg of ibuprofen or 60 mg of prednisone for the first day), tapered, and then discontinued within a few days. Glucocorticoids can also be given by intramuscular, intra-articular, or intravenous routes.
Glucocorticoids are recommended over ACTH injections or interleukin (IL-1) inhibitors. It is usually recommended that ULT not be initiated for at least 2 to 4 weeks after all signs of inflammation have subsided. This may prolong the gout attack and make it more difficult to manage. However, in gout patients with tophi, joint damage or in non-compliant patients, some specialists are comfortable beginning ULT during or shortly after the attack.
Initiating ULT
Initiating urate-lowering therapy is strongly recommended in patients with more than 2 gout attacks annually and any patient with radiologic joint damage from gout or with tophi on examination. In patients with less frequent flares, initiating ULT is also recommended, especially if the serum uric acid value is quite elevated (> 8 mg/dl to 9 mg/dl) or if there is a history of kidney disease or kidney stones. It is recommended to not begin ULT in patients after just one attack of gout or in an individual with asymptomatic hyperuricemia.
Begin ULT:
in patients with > 2 attacks annually, and any patient with joint damage or tophi
in patients with less frequent, but recurrent attacks and a significantly elevated serum uric acid (> 8-9 mg/dl) or with renal disease or previous kidney stones
ULT is not generally recommended after the first attack of gout or as treatment for asymptomatic hyperuricemia
Concomitant Therapy
Use concomitant anti-inflammatory prophylaxis to prevent gout flare when initiating ULT. It is strongly recommended that anti-inflammatory prophylaxis therapy be started at the initiation of ULT and continued for 3 to 6 months. Low-dose colchicine (0.6 mg/day) or modest doses of NSAIDS are recommended. If uric acid serum levels at 3 to 6 months are normal and no further gout attacks have occurred, the anti-inflammatory should be discontinued.
When prescribing concomitant anti-inflammatory prophylaxis to prevent gout flare when starting ULT as such:
0.6 mg colchicine or modest doses of NSAIDS daily
continue for 3 to 6 months
discontinue once uric acid target is reached and there are no further gout attacks