Alyssa Matulich
Acute Gout
Clinical Presentation: rapid onset and buildup of extreme pain that often
begins at night and is associated with warmth redness, swelling and
decreased range of motion of affected joint. The great toe is typically
affected as well as insteps, heels, knees, wrists, finger, and elbow. Systemic
symptoms may include fatigue, fever, and chills
Medications
H&P Ask about alcohol use, complete medication history, comorbidities,
observe and palpate painful joints, check for tophi and joint deformity.
Differential Diagnosis: pseudogout, cellulitis, septic arthritis, Lyme arthritis,
Psoriatic arthritis, Rheumatoid arthritis, osteoarthritis, sarcoidosis,
fracture/trauma, bursitis, dislocation, calcium apatite deposition
Diagnostics:
• Gold standard: Demonstration of monosodium urate (MSU) crystals
by polarized light microscopy in joint fluid aspirated from inflamed
joint or suspected from tophi
• Serum uric acid level: a level of greater than 6.8 mg/dL supports
gout diagnosis
• Ultrasonography: the double-contour sign or urate icing is highly
specific for gout
Plan/Management:
• Nonpharmacologic:
o Topical ice application, joint immobilization, and decreased
weight bearing may be helpful
• Pharmacologic considerations
o Should be initiated within 24 hours of onset and never
interrupted or changed during attack
o Should resolve within 48 hours if properly managed; seek
other diagnosis if symptoms not improved
o Continue therapy until acute attack resolved and consider
tapering dose in patients with multiple comorbidities
Guidelines:
• For mild/moderate gout (pain <6, involving <1 small joint or <2
large joint): Initial monotherapy with NSAID (1st line), oral
Abbreviated References: UptoDate; Uphold and Graham; Buttaro, Trybulski, Polgar-Bailey, and Sandburg-Cook
colchicine, or systemic corticosteroid. If patient does not respond,
consider a second agent
• For severe gout: prescribe a combination therapy such as NSAID and
colchicine, oral corticosteroid and colchicine, or intra-articular
steroid with all other agents
• NSAIDS: Start at full dose and gradually reduce
o Indomethacin: 50 mg q 8 hours for 2-3days then reduce to 25
mg q 8 hours until attack resolved (*NOT a good choice for
elderly)
o Naproxen: initially 750 mg followed by 250 mg q 8 hours
o Sulindac: 200 mg BID
o Celebrex: if other medications are contraindicated or not
tolerate prescribe 100 mg BID
• Colchicine
o Only for attacks when onset is less than 36 hours prior to
drug initiations
o Do not use if patient has received colchicine treatment in last
14 days
o Do not use in patients with GFR less than 10 ml/min
o Dosing
§ Loading dose of 1.2 mg followed by 0.6 mg one
hour later
§ Wait 12 hours then treat with 0.6 mg QD or BID
until the attack resolves
• Corticosteroids
o Choice for pregnant patients and end-stage renal disease
o Oral prednisone or prednisolone: 0.5 mg/kg per day for 5-10
days followed by discontinuation
o Oral prednisone or prednisolone: 0.5 mg/kg per day for 2-5
days, taper for 7-10 days then discontinue
o Methylprednisolone Dose Pack
o Intramuscular: triamcinolone acetonide 60 mg then prescribe
oral prednisone
o Intra-articular: dosing depends on number and size of affect
joints
References:

Buttaro, T.M, Trybulski, J., Polgar-Bailey, P., Sandburg-Cook, J. (2017).

Primary Care: A Collaborative Practice. (5th ed.). Mosby.

Uphold, C. & Graham, M. (2013). Clinical Guidelines in Family Practice.

Barmarrae Books, Inc. (5th ed). ISBN 978-0964615199

Becker, M. (2018, January 24). Treatment of gout flares. Retrieved from

https://www-uptodate-com.proxy.lib.utc.edu/contents/treatment-of-
goutflares?search=AcuteGout&source=search_result&selectedTitle=
1~150&usage_type=default&display_rank=1

Abbreviated References: UptoDate; Uphold and Graham; Buttaro, Trybulski, Polgar-Bailey, and Sandburg-Cook