10.1.4.1 Acute attacks of gout

It is important to distinguish drugs used for the treatment of acute attacks of gout from those used in the long-term control of the disease. The latter exacerbate and prolong the acute manifestations if started during an attack.

ChoiceDrugDosage
1st choice NSAIDNaproxen tablets 250mg, 500mgDose:
750mg initially, then 250mg every 8 hours until attack has passed
Or

Alternative NSAID at high dose if naproxen not tolerated or treatment failure. Choice will depend on individual patient factors.
Consider gastroprotection

2nd choice (if NSAID contra-indicated or not tolerated)Colchicine tablets 500 micrograms

Dose:
Treatment of acute attack: 500micrograms 2 to 3 times daily until attack settles or GI symptoms occur. Dose dependent on tolerance and renal function

Prevention of gout attacks during initial treatment with allopurinol or uricosuric drugs: 500 micrograms once or twice daily for up to 6 months. Dose dependent on tolerance and renal function

Caution in renal impairment

3rd choice
(if NSAID and colchicine contra-indicated or not tolerated)

Prednisolone 5mg tablets

Dose:
10-20mg once a day for 5 days*

*other regimens may be used

 

Prescribing Notes

  • Refer to the British Society for Rheumatology website for 2017 ‘Guideline on the Management of Gout’.
  • Patients with gout often have increased cardiovascular morbidity and mortality. Underlying conditions such as hypertension, diabetes or renal impairment should be identified and the patient’s overall cardiovascular risk assessed.
  • Affected joints should be rested and analgesic, anti-inflammatory drug therapy commenced immediately, and continued for 1–2 weeks or until pain settles.
  • Colchicine can be an effective alternative (in patients in whom NSAIDs are contra-indicated) but is slower to work than NSAIDs. In order to diminish the risks of adverse effects (especially diarrhoea) it should be used in doses of 500micrograms 2 to 3 times daily.
  • Opiate analgesics can be used as adjuncts.
  • Intra-articular (IA) corticosteroids are highly effective in acute gouty monoarthritis [unlicensed indication].
  • IA, oral, or IM corticosteroids can be effective in patients unable to tolerate NSAIDs, and in patients refractory to other treatments.
  • Patients can be given a supply of NSAIDs or colchicine and advised to start treatment if they feel an attack coming on. Early treatment with NSAIDs or colchicine can prevent a full blown attack of acute gout developing.
  • Aspirin is not indicated for acute attacks of gout.
  • Colchicine has a narrow therapeutic index and is extremely toxic in overdose:
    • elderly people and people with renal or hepatic impairment, gastrointestinal, or cardiac disease are at particular risk of colchicine toxicity
    • there is an increased risk of colchicine toxicity when taken with interacting drugs e.g. amiodarone, clarithromycin, ciclosporin, erythromycin, verapamil ( see appendix 1 BNF)
  • The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure and renal impairment since, unlike NSAIDs, it does not induce fluid retention; moreover, it can be given to patients receiving anticoagulants.
  • Colchicine should be continued until the patient is stabilised on allopurinol.
  • Do not start allopurinol, febuxostat, and uricosurics until the acute episode has settled. However, patients already established on these treatments should continue therapy during an acute episode.

Cautions

  • Colchicine is extremely toxic in overdose – see notes above and MHRA advice.
  • Colchicine-induced myoneuropathy may be an unrecognised condition in patients with reduced renal function who receive usual doses of colchicine. It can present as painless sub-acute muscle weakness. Dose adjustment is advised in these patients.