- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Other primarily analgesic compounds
The choice for a particular patient will depend on:
- The gap between onset of symptoms and the start of treatment
- Risks versus benefits
The European League Against Rheumatism (EULAR) guidelines recommend colchicine and/or NSAIDs as the first-line option for acute gout.
The opportunity should also be taken to discuss lifestyle issues such as weight loss, exercise, diet, alcohol consumption and fluid intake.
Non-steroidal anti-inflammatory drugs
- NSAIDs are the first-line treatment. Starting medication within 24 hours produces rapid relief. Consider giving the patient a stock to keep at home.
- There are no convincing trials supporting the use of a particular NSAID. All appear equally effective. Eight drugs are licensed for use in gout. Diclofenac, naproxen and indometacin are generally preferred.
- For patients with a high risk of gastro-intestinal adverse events, use a gastro-protective agent, simple analgesia, or colchicine.
- Tailor the dose to the needs of the patient, bearing in mind age, co-morbidity and interactions with other drugs. Aim for the highest tolerable licensed dose but be aware of recent CSM guidance to use NSAIDs for the shortest possible time in view of cardiovascular risk.
- Colchicine is an effective treatment for gout, usually starting with a loading dose of 1 mg and increasing by 0.5 mg every 2 hours until toxicity symptoms develop (nausea, vomiting, diarrhoea). Titrate up to the maximum licensed dose, according to response.
- Colchicine is particularly appropriate when NSAIDs are poorly tolerated, in patients with heart failure and in those who are on anticoagulants.
- The drug can be effective at lower doses. Titrate up to maximum licensed dose, according to response.
These can be given orally, intramuscularly, intravenously or intra-articularly.
- These are useful where NSAIDs or colchicine are contra-indicated.
- There are no definitive trials regarding dosage, but UK practice is to use short courses of lower doses - 15 mg/day or less.
- Intramuscular corticosteroid injection can be useful in podagra.
- Intra-articular administration of long-acting steroids is safe and effective in small trials (further work is needed to clarify effectiveness).
- It can be paired with aspiration of the joint - making it convenient to both aid diagnosis and manage the condition.
- It is particularly useful for those patients with a severe monoarthritis and contra-indications to NSAIDs and colchicine.
- It is also useful as it is associated with minimal adverse effects and a lower risk of drug interactions.
- It should not be undertaken if septic arthritis is suspected.
- These are useful where all other drug groups are contra-indicated or as an adjunct for pain relief.
- Start with paracetamol, taken regularly rather than 'prn'. If further analgesia is required, add codeine as a separate drug rather than in combination, so individual drugs can be titrated.
If there is no improvement after 2-3 days:
- Review the diagnosis (differentials include septic arthritis, non-urate arthropathy, other arthritides and haemochromatosis).
- Check medicine compliance.
- Increase doses to the maximum.
If the patient still fails to improve, consider combining treatments, or seek specialist advice.
Further reading & references
- The European League Against Rheumatism (EULAR). This is an organisation which represents the patient, health professional and scientific societies of rheumatology of all the European nations.
- British Society of Rheumatology
- Schlesinger N, Schumacher HR Jr; Update on gout. Arthritis Rheum. 2002 Oct 15;47(5):563-5.
- Emmerson BT; The management of gout. N Engl J Med. 1996 Feb 15;334(7):445-51.
- Zhang W, Doherty M, Bardin T, et al; EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006 Oct;65(10):1312-24. Epub 2006 May 17.
- Gout, Clinical Knowledge Summaries (2007)
- Schlesinger N; Management of acute and chronic gouty arthritis: present state. Drugs. 2004;64(21):2399-416.
- Sutaria S, Katbamna R, Underwood M; Effectiveness of interventions for the treatment of acute and prevention of recurrent gout. Rheumatology (Oxford). 2006 Nov;45(11):1422-31. Epub 2006 Apr 21.
- Hooper L, Brown TJ, Elliott R, et al; The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review. BMJ. 2004 Oct 23;329(7472):948. Epub 2004 Oct 8.
- Bandolier; NSAIDs and adverse effects 2007.
- Ahern MJ, Reid C, Gordon TP, et al; Does colchicine work? The results of the first controlled study in acute gout. Aust N Z J Med. 1987 Jun;17(3):301-4.
- Morris I, Varughese G, Mattingly P; Colchicine in acute gout. BMJ. 2003 Nov 29;327(7426):1275-6.
- Guideline for the management of gout, British Society for Rheumatology (2007)
- Underwood M; Diagnosis and management of gout. BMJ. 2006 Jun 3;332(7553):1315-19.
- Moore A, Collins S, Carroll D, et al; Paracetamol with and without codeine in acute pain: a quantitative systematic review. Pain. 1997 Apr;70(2-3):193-201.
|Original Author: Dr Gurvinder Rull||Current Version: Dr Gurvinder Rull|
|Last Checked: 20/04/2011||Document ID: 478 Version: 7||© EMIS|
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