Management of Acute Gout

See also our records on Gout and Gout Prophylaxis.

An ice pack may be useful, as may rest.^1,2 The joint should be elevated and trauma avoided.
The opportunity should also be taken to discuss lifestyle issues such as weight loss, exercise, diet, alcohol consumption, and fluid intake.³
Drug options include:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Colchicine
• Corticosteroids
• Analgesics

The choice for a particular patient will depend on contraindications, the gap between onset of symptoms and the start of treatment, and risks versus benefits. The European League Against Rheumatism (EULAR) guidelines recommends colchicine and/or NSAIDs as the first-line option for acute gout.⁴

• 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.³
• 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.³

• 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).⁴ 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.

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

• These are useful where NSAIDs or colchicine 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.^3,12
• Intra-articular aspiration and injection may be used in mono-articular gout.^4,12
• Intramuscular cortico-steroid injection can be useful in podagra.³

• These are useful where all other drug groups contraindicated 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.^3,13

If there is no improvement after 2-3 days:

• Review the diagnosis (differentials include septic arthritis, non-urate arthropathy, other arthritides and hemochromatosis)
• Check medicine compliance
• Increase doses to the maximum

If the patient still fails to improve consider combining treatments, or seek specialist advice.