The treatment for acute gout involves several options, including non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, colchicine, and interleukin-1 inhibitors. The choice of treatment depends on patient factors and preferences, as well as the severity of the flare.
NSAIDs
- Effectiveness: NSAIDs are commonly used to treat acute gout and have been shown to be effective in reducing pain and inflammation
- Guidelines recommendation: The British Society for Rheumatology (BSR) 2017 guidelines recommend initiating an NSAID at maximum dose as first-line therapy, with the drug choice depending on patient preference, renal function, and comorbidities if not contraindicated
- COX-2 inhibitors: Cyclo-oxygenase-2 (COX-2) inhibitors, a type of NSAID, have also been shown to be effective in treating acute gout
Corticosteroids
- Administration routes: Corticosteroids, either systemic or intra-articular, are another option for the treatment of acute gout
- Use in NPO patients: The American College of Rheumatology (ACR) 2020 guidelines recommend selecting corticosteroids (intramuscular, intravenous, or intra-articular) in patients with gout who may receive nothing by mouth (NPO)
- Efficacy and safety: A systematic review of randomized controlled trials found no evidence that corticosteroids and NSAIDs have different efficacy in managing pain in acute gout, but corticosteroids appear to have a more favorable safety profile for selected adverse events
Colchicine
- First-line option: Colchicine is another first-line option for the management of acute flares
- Dosing guidelines: The ACR 2020 guidelines recommend selecting low-dose colchicine in patients with gout when colchicine is the chosen agent
Interleukin-1 inhibitors
- When to consider: Interleukin-1 inhibitors, such as canakinumab, rilonacept, or anakinra, may be considered in patients who have not responded adequately to standard treatment of acute gout
- Guidelines recommendation: The European League Against Rheumatism (EULAR) 2017 guidelines recommend initiating IL-1 inhibitors for the treatment of flares in patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids (oral and injectable)
Prophylaxis
- Indication for prophylaxis: Prophylaxis against acute attacks is recommended when initiating or uptitrating any urate-lowering therapy and should be continued for up to 6 months
- Alternative options: The EULAR 2017 guidelines recommend initiating prophylaxis with low-dose NSAIDs, if not contraindicated, in patients with contraindications to or not tolerating colchicine
In conclusion, the treatment of acute gout involves a combination of anti-inflammatory medications, with the choice of treatment depending on the patient's specific circumstances, including comorbidities, contraindications, and preferences. NSAIDs, corticosteroids, and colchicine are first-line therapies, while interleukin-1 inhibitors are reserved for patients who do not respond to or cannot tolerate these treatments. Prophylaxis against acute attacks is also recommended when initiating or adjusting urate-lowering therapy to prevent future flares.