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Recommended treatment options for acute gouty arthritis. |
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| Drug |
Example regimens |
Major considerations |
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| NSAIDs (selected agents; no study has shown differences among NSAIDs in efficacy) |
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| 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 |
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| 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 |
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| 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 |
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| Triamcinolone acetonide |
60 mg intramuscularly once |
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| Intra-articular corticosteroids |
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| 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 |
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| 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) |
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| Colchicine (oral) |
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| 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 |
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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 |
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