Treatment
3
Figure 1. Management of an Acute Gout Attack
General Principles:
• Acute gouty arthritis attacks should be treated with pharmacologic therapy. (C)
• To provide optimal care, pharmacologic treatment should be initiated within 24 hours
of acute gout attack onset. (C)
• Ongoing pharmacologic ULT should not be interrupted during an acute gout attack. (C)
Mild-Moderate Pain, particularly for
an attack affecting only 1 or a few small
joints or 1–2 large joints
NSAID (A) (
a
or
COX-2 inhibitor)
Systemic
Corticosteroids (A)
Supplement with Topical Ice as needed (B)
Colchicine
b
(A)
Patient Education: including diet
and lifestyle; role of uric acid
excess in gout and as key treatment
target; prompt self-treatment of
subsequent acute gout attacks (B)
Consider indications for ULT or
adjustment of ongoing ULT
(See Gout Managing
Hyperuricemia Pocket Card) (C)
Monotherapy (A)
Option:
Initial combination
therapy (See Table 2) (C)
Inadequate Response
c
Successful Outcome
Switch to alternate
monotherapy (C)
Option: Add-on
combination therapy
(C) (See Table 2)
Inadequate Response
c
Off-Label Therapies in Development
d
a
Selective COX-2 inhibition with agents available outside the USA such as etoricoxib (A) was
recommended as an option in patients with GI contra-indications or intolerance to NSAIDs, but selective
COX-2 inhibition shares many adverse events with NSAID therapy. COX-2 inhibition therapy with
celecoxib (B) requires high doses and has an unclear risk-benefit ratio at this time.
b
Colchicine was recommended as an appropriate option for acute gout if started within 36 hours of
symptom onset.
c
Inadequate response is defined as: <20% improvement in pain score within 24 hours or <50% at ≥24 hours
d
Off-label use of biologic IL-1 inhibitor treatment has been investigated for acute gout when non-biologic
therapeutic categories are ineffective or contraindicated, but this approach is not approved for gout by
medical regulatory agencies at the time this is written.
Assess Severity
Severe Pain, particularly for a
polyarticular attack or an attack
affecting multiple large joints
