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.

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

• 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 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.

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.

• 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

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.