Table 1

Recommended treatment options for acute gouty arthritis.

Drug

Example regimens

Major considerations


NSAIDs (selected agents; no study has shown differences among NSAIDs in efficacy)

Naproxen

750–1000 mg orally for 3 days followed by 500–750 mg orally daily for 4–7 days

There may be cost savings relative to other treatments for acute attacks

Sulindac

300–400 mg orally for 7–10 days

Should be avoided in patients with renal or hepatic failure and patients at risk for clinically significant gastrointestinal events

Indomethacin

150–200 mg orally for 3 days followed by 100 mg orally daily for 4–7 days

Consider co-administration of PPI in patients at risk for clinically significant gastrointestinal events

COX-2 inhibitors

Celecoxib

400 mg orally on the first day, then 200 mg/day (in two divided doses) for 6–10 days

May provide better gastrointestinal tolerability than NSAIDs

Gastrointestinal protective effect lost in patients taking concomitant aspirin

Potential risk for cardiovascular adverse events, including hypertension

Systemic corticosteroids

Prednisone

40–60 mg/day for 3 days, then decrease by 10–15 mg/day every 3 days until discontinuation

Avoid use if joint sepsis not excluded

Avoid in patients subject to hyperglycemia

Methylprednisolone

100–150 mg per day for 1–2 days

Triamcinolone acetonide

60 mg intramuscularly once

Intra-articular corticosteroids

Triamcinolone acetonide

10 mg in knees and 8 mg in small joints intra-articularly once

Only useful in patients with one or a few affected joints

Avoid use if joint sepsis is not excluded

ACTH

25 USP units subcutaneously for acute small-joint monoarticular gout; 40 USP units intramuscularly or intravenously for larger joints or polyarticular gout

Not universally available

Less effective in patients receiving long-term oral corticosteroid therapy

Risk for corticotrophin hypersensitivity (less frequent with synthetic formulation)

Colchicine (oral)

For acute episodes within the first 24 hours in patients not already on prophylactic low-dose colchicine: 0.6 mg initially followed by additional doses of 0.6 mg every hour (typically for a total of three to four doses, but to a maximum of eight doses because more prolonged dosing often causes significant diarrhea, which can be accompanied by nausea and vomiting and may be severe enough to promote dehydration). This regimen can be used as an adjunct to other modalities and is typically followed by a daily low-dose oral colchicine regimen to prevent rebound

Avoid or reduce dose in elderly or frail patients or those with renal or hepatic dysfunction

All patients who receive therapeutic dosages of colchicine will develop toxic effects

Potential drug interactions with erythromycin, simvastatin, and cyclosporine; may increase risk for colchicine-induced toxic effects

Avoid intravenous colchicines


Adapted with modifications from Terkeltaub RA [42]. ACTH, adrenocorticotropic hormone; COX, cyclo-oxygenase; NSAID, nonsteroidal anti-inflammatory drug; PPI, proton pump inhibitor.

Cronstein and Terkeltaub Arthritis Research & Therapy 2006 8(Suppl 1):S3   doi:10.1186/ar1908