Acute gout is usually a self limiting condition with spontaneous recovery seen in 1-2 weeks. More prolonged recurrent acute attacks may not resolve without treatment (1).
All patients with acute gout should be offered treatment as quickly as possible after onset of an acute attack. Treatment should be continued until the attack is terminated (1–2 weeks) (1)
- non pharmacological methods include:
- rest
- increased fluid intake
- local application of an ice pack to an affected joint can also help to reduce pain and inflammation
- pharmacological methods
- nonsteroidal anti-inflammatory drugs (NSAIDs), oral colchicine and glucocorticoids may be used as first-line treatments
- the choice will depend on patient and physician preference, comorbidities (especially a history of CKD and gastrointestinal [GI] disease) and the severity of the gout
- it may be necessary to continue treatment for an additional 7 to 10 days.
- NSAID
- fast-acting oral NSAIDs at maximum doses are the drugs of choice when there are no contraindications:
- indomethacin, or naproxen
- azapropazone -
- is licensed for acute gout that has not responded to other less toxic NSAIDs (3) but is associated with a very high risk of upper gastrointestinal adverse effects, hence has largely been abandoned in clinical practice (1).
- note also that there is study evidence that etoricoxib at a dosage of 120 mg once daily was comparable in efficacy to indomethacin at a dosage of 50 mg 3 times daily, and it was generally safe and well tolerated (1)
- colchicine:
- can be an effective alternative but is slower to work than NSAIDs.
- in order to diminish the risks of adverse effects (especially diarrhoea) it should be used in doses of 0.5mg, two times a day.
- this can be used as an alternative in:
- in patients with peptic ulcer disease
- can be combined with anticoagulation
- does not cause fluid retention
- in patients with hypertension
- high-dose colchicine is not indicated and should not be prescribed (1).
- a corticosteroid,
- is an effective treatment in the management of acute gout in patients who cannot tolerate NSAIDs or are refractory to other treatments.
- can be given orally, i.m., i.v. or intra-articularly (1)
- there is study evidence that, for relieving the pain of acute gout-like arthritis, oral prednisolone plus paracetamol was as effective as indomethacin plus paracetamol but had fewer adverse efects (5)
- oral prednisolone and naproxen are equally effective in the initial treatment of gout arthritis over 4 days (6)
- patients were randomised to receive either prednisolone (35 mg once a day; n=60) or naproxen (500 mg twice a day; n=60), for 5 days
- intra-articular administration of a corticosteroid in those with a monoarthritis, is highly effective in terminating an attack (1)
Simple and opiate analgesics can be used as clinical adjuncts in those whose pain is not entirely controlled with conventional therapy (1).
Symptoms and signs should begin to subside in 12-24h if not then reconsider the diagnosis.
Allopurinal should not be used during an acute attack.
- it may prolong the attack or precipitate a further acute attack
- but in patients already established on allopurinol,it should be continued and the acute attack should be treated conventionally (1)
Follow-up after an acute flare (7)
- consider a follow-up appointment after a gout flare has settled to:
- measure the serum urate level
- provide information about gout and how to self-manage and reduce the risk of future flares
- explain to people with gout that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels
- advise them to follow a healthy, balanced diet
- advise people with gout that excess body weight or obesity, or excessive alcohol consumption, may exacerbate gout flares and symptoms
- assess lifestyle and comorbidities (including cardiovascular risk factors and CKD
- review medications and discuss the risks and benefits of long-term ULT (urate lowering therapy)
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