Diagnosis
Most cases of gout are characterized by rapid onset of monoarticular arthritis resulting from deposition of urate crystals and a subsequent inflammatory response. The joint most commonly affected by gout is the first metatarsal phalangeal joint; the knee is the second most commonly involved joint. The diagnosis of acute gout was made based on the presence of the characteristic clinical history with urate crystals in the joint fluid.3
Management
Three treatments are available for patients suffering from acute gouty arthritis.
Colchicine inhibits microtubule formation and thus interferes with phagocytosis of the crystals, attenuating the inflammatory response. It also inhibits the release of chemotactic factors reducing the migration of neutrophils into the joint. In a randomized controlled trial, two thirds of patients treated with colchicine improved after 48 hours, but only one third of the patients receiving placebo demonstrated similar improvement. Improvement occurred earlier in the colchicine-treated patients. There were significant differences compared with placebo after 18–30 hours. All patients given colchicine (mean dose of 6.7 mg) developed diarrhea after a median time of 24 hours. Diarrhea occurred before relief of pain in most patients.4
The principal side effects of colchicine are gastrointestinal symptoms including abdominal pain and diarrhea. The dose associated with these symptoms is very close to the therapeutic dose.
Generally the initial dose is 1 mg, with 0.5 mg added every 2 hours until a total dose of up to 8 mg has been reached, or abdominal symptoms develop3 (Level of evidence, 1b; single RCT).4
Another option for treatment of acute gout is nonsteroidal anti-inflammatory agents. Indomethacin has been the standard for years but there is no proof that it is better than other NSAIDs5-8 (Level of evidence, 1b; a set of RCTs). The starting dose is 50 mg tid, tapered over approximately 1 week as symptoms subside. NSAIDs are also limited by their gastrointestinal and renal side effects.
Intra-articular injection of corticosteroids is an additional treatment for acute gout. The dose given depends on the size of the affected joint. The appropriate dose of methylprednisolone would be 5–10 mg for a small joint and 20–60 mg for a large joint such as the knee1 (Level of evidence, 5; expert opinion).