Gout – ACR 2012 Guideline Part 2

Summary:

1. Acute gouty Tx should be initiated within 24hr of onset
2. Established urate-lowering Tx should be continued during an acute attack
3. 1st line: NSAIDS, corticosteroids, or coral colchicine (combination for severe or refractory attacks)
4. Anti-inflammatory prophylaxis for all gout pt when urate lowering Tx is initiaed and continued if any clinical evidence of gout activity and/or serum urate target hasn’t achieved.
   • 1st line gout attack prophylaxis Tx
     • Colchicine po – , with adjustment in CKD & drug interaction unless there is a lack of tolerance or c/i
     • Low-dose NSAID Tx unless there is a lack of tolerance or c/i

Severity of Acute Gouty arthritic attack – self-reported pain (0-10 scale)

• Mild <=4, Moderate 5-6, Severe >=7

Duration of the gouty arthritis attack since onset

• Early <12 hr, Well-established 12-36hr, late >36hr

Extent of acute gouty arthritis attack

1. One or a few small joints
2. 1 or 2 large joints: ankle, knee, wrist, elbow, hip, shoulder
3. Polyarticular:
   • >=3 separate large joints
   • >= 4 joints, involving more than 1 region: forefoot (MTP, toes), midfoot (tarsal jt), ankle/hindfoot, knee, hip, fingers, wrist, elbow, shoulder, other

Management of an Acute Gout Attack: Assess Severity

• Initiate med Tx within 24hr of onset & continue ULT (don’t interrupt)

A) Mild-Moderate pain affect 1 -2 large joints or a few small joints → Monotherapy

1. NSAIDs > COX-2 – continue full dose until gouty attack has completely resolved
2. Systemic Corticosteroids: (4 options)
   • Prednisone 0.5mg/kg/d for 5-10days then stop
   • Prednisone 0.5mg/kg/d for 2-5 days then taper for 7-10 days then stop
   • If 1-2 large joints: consider intra-articular corticosteroids
   • Triamcinolone acetonide 60mg IM then oral prednisone as above
3. Colchicine (within 36hr) – 1.2mg then 0.6mg 1hr later + prophylaxis dosing 12hr later & continue until the attack resolves
   • Use NSAIDs or steroids if colchicine in the last 14 days

• Inadequate Response (<20% improvement <= 24hr or <50% >=24hr)
  • switch to alt monotherapy or combination therapy
• Successful Outcome
  • Pt education: Lifestyle, prompt self-tx of subsequent acute gout attacks & consider ULT

B) Severe pain, polyarticular attack or affecting multiple large joints → Combination therapy

1. Colchicine + NSAIDs
2. Oral corticosteroids + colchicine
3. Intra-articular steroids + all other modalities
4. (no oral corticosteroids + NSAIDs – synergistic GI toxicity)

Gout attack prophylaxis – With or just prior to initiating ULT

1. 1st line:
   • Low dose colchicine: 0.5mg od – bid
   • Low dose NSAIDs with PPi: Naproxen 250mg bid
2. 2nd line: If both NSAIDs and colchicine not tolerated, contra-indicated, or ineffective
   • Low dose Prednisone or Prednisolone (<=10mg/d)
3. Duration:
   • + gout activity → Continue pharmacologic prophylaxis
   • no s/sx (3 options) → at least 6 months of prophylaxis OR
     • 3 months after achieving target serum urate (no tophi)
     • 6 months after achieving target serum urate (+ tophi)

NPO Pt

1. Initial ACTH 25-40IU sc
2. Intra-articular corticosteroids – dose varies by jt size
3. Methylprednisolone 0.5-2mg/kg IV/IM