1. Immediate Pharmacological Therapy

Goal: Stop inflammation and relieve pain.

1. a) NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) → First-line treatment

Examples:

• Ibuprofen
• Diclofenac
• Naproxen
• Indomethacin (classic for gout)

They act quickly to reduce inflammation.
Do not use in patients with kidney failure, stomach ulcers, or bleeding risk.

1. b) Colchicine

Most effective when taken early in the attack.
Modern dosing is generally low (exact dosage per physician instruction).

Particularly useful when NSAIDs are not suitable.
Caution in patients with kidney disease or those taking interacting medications.

1. c) Glucocorticoids

Used when NSAIDs or colchicine are unsuitable.

Forms:

• Tablets (e.g., prednisolone)
• Injection directly into the joint (intra-articular) → highly effective for single-joint attacks

Very effective and provides rapid pain relief.

2. Physical Measures

• Cool the joint (ice packs, 10–20 min)
• Elevate the joint
• Rest the joint
• Drink plenty of fluids

3. What NOT to do during an acute gout attack

• Do not start new uric acid–lowering medication → may worsen the attack
• Do not suddenly stop allopurinol if already taking it
• No alcohol
• No purine-rich food
• Avoid intense physical exertion

4. When medical evaluation is important

• First-ever gout attack
• Uncertain diagnosis (might be a joint infection → dangerous!)
• Fever or feeling unwell
• Attacks are becoming more frequent
• Multiple joints affected
• Patients with kidney disease, heart failure, or diabetes

5. Additional supportive measures

• 2–3 liters of water per day
• Light, low-purine meals
• Completely avoid alcohol
• Cherry juice or cherries can reduce inflammation (well documented)

6. Reducing Attack Frequency Long-Term

After the acute attack has resolved:

• Uric acid–lowering therapy (e.g., allopurinol, febuxostat)
• Dietary modification (low purine, low sugar, low alcohol)
• Weight reduction (slowly!)
• Avoid triggers (diuretics, beer, meat broths, etc.)

Medication Overview for Acute and Long-Term Gout Therapy

A safe, medically sound summary of the main medications used for acute gout attacks and long-term treatment — including general dosing principles (no specific mg values).

1. Medications for Acute Gout Attacks
2. A) NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

Examples: ibuprofen, naproxen, diclofenac, indomethacin
Effect: anti-inflammatory, pain-relieving

Dosing principles:

• Start quickly, ideally within the first 24 hours
• Short-term higher anti-inflammatory doses, then taper
• Not suitable for patients with stomach problems, kidney failure, or heart failure

1. B) Colchicine

Effect: inhibits the inflammatory reaction caused by urate crystals

Dosing principles:

• Low-dose modern regimen (no more high “loading doses”)
• Best taken early in the attack
• Caution with kidney or liver impairment, and with certain interacting drugs (e.g., macrolide antibiotics)

1. C) Glucocorticoids

Examples: prednisolone
Effect: very strong anti-inflammatory action

Dosing principles:

• Short-term high anti-inflammatory dose, then taper
• Useful when NSAIDs or colchicine are not suitable
• Intra-articular injection possible for single-joint involvement

1. D) IL-1 Inhibitors (for severe cases)

Example: anakinra (rare, off-label, used in hospitals)

Dosing principles:

• Only for severe, treatment-resistant, or contraindicated cases
• Daily injections for several days

Important during an acute attack

• Do not start new uric acid–lowering therapy
• Do not stop existing uric acid–lowering medication suddenly

2. Medications for Long-Term Uric Acid Reduction

These prevent future gout attacks, lower uric acid permanently, and dissolve crystals over time.

1. A) Allopurinol (first-line treatment)

Effect: decreases uric acid production (xanthine oxidase inhibitor)

Dosing principles:

• Start low, increase slowly every 2–4 weeks
• Dose adjusted according to target uric acid level (<6 mg/dL; <5 mg/dL in tophaceous gout)
• Must be adapted in patients with kidney impairment

1. B) Febuxostat

Effect: also a xanthine oxidase inhibitor

Dosing principles:

• Start with low standard dose
• Effective even in kidney disease (often without major adjustments)
• Alternative if allopurinol is not tolerated
• Caution in severe cardiovascular disease

1. C) Uricosurics (increase uric acid excretion)

Examples: benzbromarone, probenecid

Dosing principles:

• Start low, increase slowly
• Suitable only for patients with good kidney function
• High fluid intake recommended (higher risk of kidney stones)

1. D) Combination Therapy

Allopurinol + probenecid can be used when monotherapy is insufficient.

3. Prophylaxis When Starting Allopurinol or Febuxostat

Starting uric acid–lowering therapy can trigger gout attacks.
Therefore:

• Low-dose colchicine or
• Low-dose NSAID

for at least 3–6 months to prevent attacks.

4. Target Levels

• Uric acid < 6 mg/dL
• With tophi: < 5 mg/dL

5. Non-Pharmacological Measures