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| ==[[Treatment]]== | | ==[[Treatment]]== |
| [[Clinical practice guideline]]s address treatment.<ref name="pmid23024029">{{cite journal| author=Khanna D, Khanna PP, Fitzgerald JD, Singh MK, Bae S, Neogi T et al.| title=2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. | journal=Arthritis Care Res (Hoboken) | year= 2012 | volume= 64 | issue= 10 | pages= 1447-61 | pmid=23024029 | doi=10.1002/acr.21773 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024029 }} </ref><ref name="pmid23024028">{{cite journal| author=Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T et al.| title=2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. | journal=Arthritis Care Res (Hoboken) | year= 2012 | volume= 64 | issue= 10 | pages= 1431-46 | pmid=23024028 | doi=10.1002/acr.21772 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024028 }} </ref><ref name="pmid16707532">{{cite journal |author=Zhang W, Doherty M, Bardin T, ''et al'' |title=EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) |journal=Ann. Rheum. Dis. |volume=65 |issue=10 |pages=1312–24 |year=2006 |month=October |pmid=16707532 |doi=10.1136/ard.2006.055269 |url=http://ard.bmj.com/cgi/pmidlookup?view=long&pmid=16707532 |issn=}}</ref> However, trials comparing [[glucocorticoid]]s ([[glucocorticoid|steroids]]) and [[non-steroidal anti-inflammatory agent]]s (NSAIDs) were not published till after the guidelines.
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| A nurse-led protocol with treatment goal of 6 mg/dL was beneficial<ref name="pmid30343856">{{cite journal| author=Doherty M, Jenkins W, Richardson H, Sarmanova A, Abhishek A, Ashton D et al.| title=Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. | journal=Lancet | year= 2018 | volume= 392 | issue= 10156 | pages= 1403-1412 | pmid=30343856 | doi=10.1016/S0140-6736(18)32158-5 | pmc=6196879 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30343856 }} </ref>.
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| Regarding [[medication]]s, if there are no mitigating factors in choosing a drug, [[glucocorticoid]]s, [[non-steroidal anti-inflammatory agent]]s (NSAIDs), and [[colchicine]] all work; however, [[colchicine]] consistently causes [[drug toxicity]].
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| A combination treatment is ice four times a day with oral prednisone 30 mg orally tapered over 6 days (30 mg for two days, 20 mg for two days, 10 mg for two days) and colchicine 0.6 mg/day.<ref name="pmid11838852">{{cite journal |author=Schlesinger N, Detry MA, Holland BK, ''et al'' |title=Local ice therapy during bouts of acute gouty arthritis |journal=J. Rheumatol. |volume=29 |issue=2 |pages=331–4 |year=2002 |pmid=11838852 |doi=}}</ref> An advantage of this regimen is the reduced toxicity from the low dose of colchicine and that the colchicine helps prevent flares if allopurinol is later started. Colchicine has been combined with NSAIDs<ref name="pmid15570646">{{cite journal |author=Borstad GC, Bryant LR, Abel MP, Scroggie DA, Harris MD, Alloway JA |title=Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis |journal=J. Rheumatol. |volume=31 |issue=12 |pages=2429–32 |year=2004 |month=December |pmid=15570646 |doi= |url=http://www.jrheum.com/subscribers/04/12/2429.html |issn=}}</ref> that are not metabolized by the CYP3A4 [[isoenzyme]] of [[cytochrome P-450]] ([[naproxen]] is not metabolized by CYP3A4). Combining [[glucocorticoid]]s with NSAIDs increased the risk for gastrointestinal [[drug toxicity]]<ref name="pmid1892140">{{cite journal |author=Fries JF, Williams CA, Bloch DA, Michel BA |title=Nonsteroidal anti-inflammatory drug-associated gastropathy: incidence and risk factor models |journal=Am. J. Med. |volume=91 |issue=3 |pages=213–22 |year=1991 |month=September |pmid=1892140 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9343(91)90118-H |issn=}}</ref>
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| ===Local ice===
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| Ice packs, applied for 30 minutes 4 times per day, can help according to a [[randomized controlled trial]] without allocation concealment.<ref name="pmid11838852">{{cite journal |author=Schlesinger N, Detry MA, Holland BK, ''et al'' |title=Local ice therapy during bouts of acute gouty arthritis |journal=J. Rheumatol. |volume=29 |issue=2 |pages=331–4 |year=2002 |pmid=11838852 |doi=}}</ref> In this trial, ice reduced the [[pain measurement|visual pain analog score]] by an additional 33 mm beyond the reduction provided by a combination of [[glucocorticoid]]s and [[colchicine]].
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| ===Non-steroidal anti-inflammatory agents===
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| [[Non-steroidal anti-inflammatory agent]]s (NSAIDs) are better than placebo according to a [[randomized controlled trial]] of 30 total patients.<ref>García de la Torre, Ignacio. (1987) Estudio doble-ciego paralelo, comparativo con tenoxicam vs placebo en artritis gotosa aguda (A comparative, double-blind, parallel study with tenoxicam vs placebo in acute gouty arthritis). ''Invet Med Int '14:'''92–7 [[http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=62234&indexSearch=ID Abstract in Spanish]]</ref> According to a summary of this trial, "the knee was affected in 14 cases and the great toe in only two cases. After 24 h, 67% of tenoxicam group had ≥50% reduction in pain compared with 26% of placebo group (P<0.05). However, at the end of the treatment (4 days), there was no significant difference between the groups."<ref name="pmid16632483">{{cite journal |author=Sutaria S, Katbamna R, Underwood M |title=Effectiveness of interventions for the treatment of acute and prevention of recurrent gout--a systematic review |journal=Rheumatology (Oxford) |volume=45 |issue=11 |pages=1422–31 |year=2006 |month=November |pmid=16632483 |doi=10.1093/rheumatology/kel071 |url=http://rheumatology.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16632483 |issn=}}</ref>
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| ===Glucocorticoids===
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| {| class="wikitable" align="right"
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| |+ Comparison of NSAID and steroids for acute gout
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| ! rowspan="2"| !!rowspan="2"| Patients!!colspan="2"|Interventions !! rowspan="2"|Results
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| ! [[Glucocorticoid|Steroid]]||[[Non-steroidal anti-inflammatory agent|NSAID]]
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| | Janssens et al 2008<ref name="pmid18514729">{{cite journal |author=Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C |title=Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial |journal=Lancet |volume=371 |issue=9627 |pages=1854–60 |year=2008 |month=May |pmid=18514729 |doi=10.1016/S0140-6736(08)60799-0 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)60799-0 |issn=}}</ref>
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| ||120 total patients with [[uric acid]] crystals on [[arthrocentesis]]
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| ||[[Prednisolone]] 35 mg once daily for 5 days
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| ||[[Naproxen]] 500 mg twice daily for 5 days
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| ||NSAID trended better (88% versus 80% response; p=0.3)<br/>No differences in rates of [[drug toxicity]].
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| | Man et al 2007<ref name="pmid17276548">{{cite journal |author=Man CY, Cheung IT, Cameron PA, Rainer TH |title=Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial |journal=Annals of emergency medicine |volume=49 |issue=5 |pages=670–7 |year=2007 |pmid=17276548 |doi=10.1016/j.annemergmed.2006.11.014}}</ref>
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| ||90 total patients with clinical diagnosis of gout†
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| ||Initially [[prednisolone]] 30 mg<br/>Followed by prednisolone 30 mg daily for 5 days and as needed [[acetaminophen]]
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| ||Initially [[diclofenac]] 75 mg with [[indomethacin]] 50 mg<br/>Followed by indomethacin 50 mg every 8 hrs for 2 days then 25 mg every 8 hrs for 3 days and as needed [[acetaminophen]].
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| ||Steroids faster reduction in pain.<br/>Steroids used more [[acetaminophen]].<br/>More adverse effects from [[indomethacin]].<br/>
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| [[Indomethacin]] trended to more relapses at 2 weeks (11% vs 17%).
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| |colspan="5"|Notes:<br/>
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| † Clinical diagnosis of gout was "pain and warmth in a joint, and presented within 3 days of the onset of pain and also had 1 or more of the following: metatarsal-phalangeal joint involvement; knee or ankle joint involvement and aspirate containing crystals; or typical gouty arthritis, with either gouty tophi present or previous joint aspiration confirming the diagnosis of gout." Seven patients allowed arthrocentesis and all were positive for gout.
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| |}
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| [[Randomized controlled trial]]s find similar benefit from [[non-steroidal anti-inflammatory agent]]s and oral [[glucocorticoid]]s. In the first trial the reduction in [[pain measurement|visual analog scale]] after 5 days was 44.7 with [[prednisolone]] and 46.0 with [[naproxen]].<ref name="pmid17276548">{{cite journal |author=Man CY, Cheung IT, Cameron PA, Rainer TH |title=Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute gout-like arthritis: a double-blind, randomized, controlled trial |journal=Annals of emergency medicine |volume=49 |issue=5 |pages=670–7 |year=2007 |pmid=17276548 |doi=10.1016/j.annemergmed.2006.11.014}}</ref> Less [[adverse drug reaction]]s occurred in the [[glucocorticoid]]s group; however, the NSAID group received a high dose (50 mg every 8 hours for 2 days, followed by 25 mg every 8 hours for 3 days)<ref name="pmid8664664">{{cite journal |author=Henry D, Lim LL, Garcia Rodriguez LA, ''et al'' |title=Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis |journal=BMJ |volume=312 |issue=7046 |pages=1563–6 |year=1996 |month=June |pmid=8664664 |pmc=2351326 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=8664664 |issn=}}</ref>.
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| In the second [[randomized controlled trial]] statistically equal effect resulted from prednisolone 35 mg orally per day or naproxen 500 mg orally twice per day; however there was an insignificant 8% improvement in the NSAID group.<ref name="pmid18514729">{{cite journal |author=Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C |title=Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial |journal=Lancet |volume=371 |issue=9627 |pages=1854–60 |year=2008 |month=May |pmid=18514729 |doi=10.1016/S0140-6736(08)60799-0 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)60799-0 |issn=}}</ref> There were no significant differences in [[drug toxicity]].
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| ===Colchicine===
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| [[Colchicine]] is better than placebo according to a [[systematic review]] by the [[Cochrane Collaboration]]<ref name="pmid17054279">{{cite journal |author=Schlesinger N, Schumacher R, Catton M, Maxwell L |title=Colchicine for acute gout |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD006190 |year=2006 |pmid=17054279 |doi=10.1002/14651858.CD006190 |url=http://dx.doi.org/10.1002/14651858.CD006190 |issn=}}</ref> that found a single [[randomized controlled trial]] of 43 patients<ref name="pmid3314832">{{cite journal |author=Ahern MJ, Reid C, Gordon TP, McCredie M, Brooks PM, Jones M |title=Does colchicine work? The results of the first controlled study in acute gout |journal=Aust N Z J Med |volume=17 |issue=3 |pages=301–4 |year=1987 |month=June |pmid=3314832 |doi=10.1111/j.1445-5994.1987.tb01232.x |url= |issn=}} [http://www.medicine.ox.ac.uk/bandolier/booth/gout/colchrct.html Summary at Bandolier]</ref>. In this study, colchicine 1 mg orally, followed by 0.5 mg every two hours led to a 50% reduction in pain in about 70% of patients compared to about 35% of patients who received placebo. However, all patients had [[drug toxicity]] from colchicine and in 90% of the patients toxicity occurred before 50% reduction in pain.
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| Regarding the best dose, 1.2 mg followed by 0.6 mg in 1 hour may be as effective as higher dose.<ref name="pmid20131255">{{cite journal| author=Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW| title=High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. | journal=Arthritis Rheum | year= 2010 | volume= 62 | issue= 4 | pages= 1060-8 | pmid=20131255
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| | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20131255 | doi=10.1002/art.27327 }} </ref>
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| To avoid [[drug toxicity]], lower doses of colchicine (0.6 per day) have been used in combination with [[glucocorticoid]]s.<ref name="pmid11838852">{{cite journal |author=Schlesinger N, Detry MA, Holland BK, ''et al'' |title=Local ice therapy during bouts of acute gouty arthritis |journal=J. Rheumatol. |volume=29 |issue=2 |pages=331–4 |year=2002 |month=February |pmid=11838852 |doi= |url=http://www.jrheum.com/subscribers/02/02/331.html |issn=}}</ref> The UK National Library for Health recommends 0.5 mg two to four times a day.<ref>CKS (2007) Gout - Management (Topic Review). Clinical Knowledge Summaries. http://cks.library.nhs.uk/gout/management [Accessed: Date]</ref>
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| ===Anti-cytokines===
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| The [[monoclonal antibody]] against [[interleukin]]-1 beta, [[canakinumab]], may help according to a [[randomized controlled trial]].<ref name="pmid20533546">{{cite journal| author=So A, De Meulemeester M, Pikhlak A, Yücel AE, Richard D, Murphy V et al.| title=Canakinumab for the treatment of acute flares in difficult-to-treat gouty arthritis: Results of a multicenter, phase II, dose-ranging study. | journal=Arthritis Rheum | year= 2010 | volume= 62 | issue= 10 | pages= 3064-76 | pmid=20533546 | doi=10.1002/art.27600 | pmc= | url= }} </ref>
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| ==Prognosis== | | ==Prognosis== |
