See also our records on Gout and Gout Prophylaxis.

General points

An ice pack may be useful, as may rest.^1,2 The joint should be elevated and trauma avoided.

Pharmacological therapeutic options include:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Colchicine
• Corticosteroids
• Other primarily analgesic compounds

The choice for a particular patient will depend on:

• Contra-indications
• 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.³

The opportunity should also be taken to discuss lifestyle issues such as weight loss, exercise, diet, alcohol consumption and fluid intake.⁴

Non-steroidal anti-inflammatory drugs

• NSAIDs are the first-line treatment. Starting medication within 24 hours produces rapid relief.⁵ Consider giving the patient a stock to keep at home.
• There are no convincing trials supporting the use of a particular NSAID.⁶ All appear equally effective. Eight drugs are licensed for use in gout. Diclofenac, naproxen and indometacin are generally preferred.⁴
• For patients with a high risk of gastro-intestinal adverse events, use a gastro-protective agent, simple analgesia, or colchicine.⁷
• Tailor the dose to the needs of the patient, bearing in mind age, co-morbidity and interactions with other drugs.⁸ 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.⁴

Colchicine

• 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).³ 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.⁹
• The drug can be effective at lower doses.¹⁰ Titrate up to maximum licensed dose, according to response.

Corticosteroids

These can be given orally, intramuscularly, intravenously or intra-articularly.¹¹

• 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.^4,12
• Intramuscular corticosteroid injection can be useful in podagra.⁴

Intra-articular steroids^3,12

• 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.

Analgesics

• 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.^4,13

What next?

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.

Document references

1. Schlesinger N, Schumacher HR Jr; Update on gout. Arthritis Rheum. 2002 Oct 15;47(5):563-5.
2. Emmerson BT; The management of gout. N Engl J Med. 1996 Feb 15;334(7):445-51. [abstract]
3. 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. [abstract]
4. Gout, Clinical Knowledge Summaries (2007)
5. Schlesinger N; Management of acute and chronic gouty arthritis: present state. Drugs. 2004;64(21):2399-416. [abstract]
6. 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. [abstract]
7. 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. [abstract]
8. Bandolier; NSAIDs and adverse effects 2007.
9. 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. [abstract]
10. Morris I, Varughese G, Mattingly P; Colchicine in acute gout. BMJ. 2003 Nov 29;327(7426):1275-6.
11. Guideline for the management of gout, British Society for Rheumatology (2007)
12. Underwood M; Diagnosis and management of gout. BMJ. 2006 Jun 3;332(7553):1315-19.
13. 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. [abstract]

Internet and further reading

• 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

Acknowledgements