Treatment of the gout attack

Gout is associated with very intense inflammation. Treatment of an attack (‘acute treatment’) needs to be aimed at:

• Suppressing inflammation to be successful

• Keeping the affected area still

• Raised

• Iced (e.g. with a packet of frozen peas)

• Simple pain killers like paracetamol, may give some relief but will not shorten the attack.

Colchicine

One of the oldest and best established treatments to reduce inflammation is a drug called colchicine. This may have been described as a treatment for gout as early as the 6th century. Colchis was a community on the Black Sea coast, from which the meadow saffron plant, or Colchicum autum, derived its name. Colchicine is an extract of this plant. It was little used as a treatment in the ‘modern’ era until it became available as a tablet in 1936. While undoubtedly effective and safe when given by mouth, it often causes diarrhoea if used in doses large enough to be effective (at least 3,500 microgram tablets daily) and takes longer to work than other treatments.

Non-steroidal anti-inflammatories (NSAIDs)

Nowadays the most widely used treatment for an attack of gout is a class of drug called non-steroidal anti-inflammatories, or NSAIDs for short. There are many varieties of NSAID, the oldest being aspirin, although this is now rarely used for this purpose.

Other common examples are ibuprofen (Nurofen® is a common brand), diclofenac (Voltarol®, Diclomax®), indometacin (Indocid®) and naproxen (Naprosyn®). There is little to choose between these in terms of effectiveness provided they are given in adequate dose. For example, the standard dose of diclofenac is 50 mg three times daily, but many doctors will suggest taking 100 mg for the first dose, technically an overdose, to combat the intense inflammation associated with gout.
Typically the drug should be started as early as possible in an attack and usually settle the attack within 3-5 days, although some relief is apparent much sooner. The drug should be continued for a few days after the symptoms have settled.

Not suitable for everybody

There are some circumstances where these drugs may not be safe and hence should be avoided, although sometimes, as the course is typically short, provided the patient is made aware of the risks, the doctor may feel that the risk is justified. Situations where these drugs are considered less safe include in the elderly (over 70 years), if there is significant kidney disease or heart failure, severe high blood pressure, asthma, a history of ulcer in the gut, liver failure, or treatment with warfarin.
Each case should of course be discussed with the doctor.

L3 COX 2-II specific NSAIDs

In recent years a class of modified NSAIDs have become available, known as COX 2-II specific NSAIDs. These have been ‘tweaked’ to try and reduce the incidence of the most common major side effect of these drugs, namely bleeding and/or ulcers of the stomach and upper gut.

They are undoubtedly associated with a lower incidence of these serious side-effects, and in effect allow a larger dose of anti-inflammatory to be given, but their popularity has been mitigated by their greater expense, and some concerns about other rare side effects.

However, they are very effective at treating gout, the most widely available being eterocoxib, or Arcoxia®, patients often feel better after only a single dose, although it can be continued for up to 10 days.

Steroid treatment for gout

For patients where colchicine or NSAIDS cannot be given, are not tolerated by the patient, or appear to be ineffective, steroid treatment is often the best option. Many people are nervous of steroids, but the side effects for which they are infamous are only relevant when the dugs are given for long periods.

Short sharp courses given to treat gout, provided these are not too frequent, are rarely associated with such side effects. In the UK the most widely used steroid is prednisolone, typically given by mouth e.g. at a dose of 20 mg daily for 10 days. However it can also be given as a single injection into the buttock, or even directly into the affected joint.

This latter route can be highly effective, and may also allow fluid to be taken from the joint for analysis and confirmation of the diagnosis. However, as discussed below, this is rarely necessary and the procedure, while short-lived, is quite painful, and not all doctors will be proficient in it. The bottom line is that steroids are a very effective and safe treatment for acute attacks of gout.

It is important to realize that these 3 treatments (colchicine, NSAIDs and steroids) are the only treatments effective at reducing inflammation and shortening the duration of an attack.

If I treat the attack and suppress the inflammation will I be allowing damage to occur?

This is a reasonable question, in that the inflammation happens because the body is attempting to rid itself of potentially damaging crystals. However, the inflammation probably inadvertently causes as much damage as the crystals themselves, so suppressing the inflammation has a net benefit, as well as getting rid of the pain!

Treatment of recurrent gout attacks and tophaceous gout

As we have already suggested, one or even several attacks of gout do not require treatment beyond the anti-inflammatory treatments discussed.

However, there are a number of circumstances where it may be recommended to have treatment which will lower the uric acid level in the blood, and so prevent further attacks; this is termed prophylactic therapy.

These are situations where:

• Attacks are frequent (eg more than 3 times per year)

• The anti-inflammatory treatments cannot be given, for whatever reason, or are ineffective

• Where there is evidence that the gout is causing trouble outside the joints, as in tophi or in the kidneys, either as kidney stones or impairment of kidney function.

If there is an obvious reason for having high uric acid levels (‘secondary gout’) which can be adjusted, this is one avenue to explore. A common example of this is where water tablets (diuterics), which happen to raise the uric acid level in the blood, are being used to treat high blood pressure.
In such circumstances it is often possible to use an alternative blood pressure tablet which does not have this effect. Similarly, low dose aspirin is frequently prescribed to reduce the risk of heart disease; while often necessary, with few alternatives as safe and cheap, it is sometimes prescribed when not strictly required.