Drug choice for the management of acute gout

There is moderate-certainty evidence that systemic corticosteroids (oral or intramuscular) are as effective as NSAIDs in the treatment of acute gout. Systemic corticosteroids; however, have a lower incidence of acute adverse effects than NSAIDs. There is moderate-certainty evidence that all NSAIDs are equally beneficial for the management of gout, although some NSAIDs may have a lower incidence of acute adverse effects and therefore the patient is less likely to stop them. For discussion on NSAID choice, see Choosing an NSAID. There is also low-certainty evidence that low-dose colchicine is effective in reducing pain and inflammation in acute gout; the number of adverse effects may be similar to NSAIDs. Paracetamol may be useful as an analgesic adjunct but is not recommended as monotherapy.

There are no randomised controlled trials investigating intra-articular or soft-tissue (eg bursal) corticosteroid injections for acute gout, but use is supported by evidence of benefit in other types of inflammatory arthritis (eg rheumatoid arthritis) and the proven effectiveness of systemic corticosteroids in acute gout. Local corticosteroid injection is appropriate if the acute attack involves 1 or 2 joints (or bursae), and joint (or bursal) infection has been excluded. Aspiration of synovial (or bursal) fluid for microscopy and culture may be required to exclude infection (see Utility of joint aspiration and synovial fluid analysis for rheumatological diseases). Unless there is a high clinical suspicion of infection (eg recent history of penetrating trauma), the corticosteroid can be injected before test results are available. Once a definitive diagnosis of gout has been made, aspiration to exclude infection is not required before local corticosteroid injection for recurrent attacks unless infection is suspected. For principles of use of local corticosteroid injections, see Principles of using local corticosteroid injections for musculoskeletal pain.

Drugs for the management of acute gout and their safety profiles gives a summary of the drugs used for the management of acute gout and their safety profiles.

Table 1. Drugs for the management of acute gout and their safety profiles
Drug choice should be individualised to the patient, their preferences, and any comorbidities.
Drug class	Safety
Corticosteroids—local or oral	Lower incidence of adverse effects than oral NSAID therapy. Can be given to populations with comorbidities in which NSAIDs are unable to be used.
NSAIDs—oral [NB1]	Higher incidence of adverse effects than corticosteroids in high-risk populations (see Choosing an NSAID for advice on NSAID choice).
Colchicine—oral	Small therapeutic window, risk of toxicity and adverse effects at higher doses.
Note: NSAID = Nonsteroidal anti-inflammatory drug NB1: NSAIDs are often the drug of choice in younger populations because they are easy to access and are less likely to cause adverse effects in younger people than in older people.