Summary:
- Acute gouty Tx should be initiated within 24hr of onset
- Established urate-lowering Tx should be continued during an acute attack
- 1st line: NSAIDS, corticosteroids, or coral colchicine (combination for severe or refractory attacks)
- 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
- 1st line gout attack prophylaxis Tx
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
- One or a few small joints
- 1 or 2 large joints: ankle, knee, wrist, elbow, hip, shoulder
- 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
- NSAIDs > COX-2 – continue full dose until gouty attack has completely resolved
- 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
- 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
- Colchicine + NSAIDs
- Oral corticosteroids + colchicine
- Intra-articular steroids + all other modalities
- (no oral corticosteroids + NSAIDs – synergistic GI toxicity)
Gout attack prophylaxis – With or just prior to initiating ULT
- 1st line:
- Low dose colchicine: 0.5mg od – bid
- Low dose NSAIDs with PPi: Naproxen 250mg bid
- 2nd line: If both NSAIDs and colchicine not tolerated, contra-indicated, or ineffective
- Low dose Prednisone or Prednisolone (<=10mg/d)
- 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
- Initial ACTH 25-40IU sc
- Intra-articular corticosteroids – dose varies by jt size
- Methylprednisolone 0.5-2mg/kg IV/IM
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