Management of Acute Gout in the Emergency Department

Properties
Naproxen
Prednisone
Triamcinolone
Colchicine
Dose
750 mg orally followed
by 250-500 mg every 8
hours until the attack
has subsided
40 mg/day for 3 to 5
days, with or without
a taper)
20-40 mg for the knee and 5
to 10 mg for smaller joints
1.2 mg PO x 1 followed by
0.6 mg an hour later*
Administration
Oral
Oral
Intra-articular
Oral
PK/PD
Onset: 0.5- 1 hr
Duration: up to 12 hrs
Renal Excretion: 95 %
Onset: 1-2 hr
Elimination ½ life 2-3
hr
Renal Excretion: >95%
Onset: 12-24 hr
Duration: up to 30 days
Renal Excretion: 75%
Onset: 0.5-2 hr
Elimination ½ life 27-31 hr
Renal Excretion: 45-65%
Adverse Effects
Edema, GI discomfort,
headache, dizziness,
renal dysfunction
Hypertension, fluid
retention,
hyperglycemia,
disturbance in mood
Headache, injection site
pain, influenza-like illness,
pharyngitis
GI discomfort, diarrhea,
nausea, neuromyopathy,
and vomiting
Drug
Interactions and
warnings
Consider against in
patients with high
bleeding risk, peptic
ulcer disease, heart
failure, dehydration,
and renal impairment.
Warning with oral
contraceptives, CVD,
diabetes, GI
problems, psychiatric
disorders, and live
vaccines
Warning if considering joint
sepsis, and in patients with
diabetes, CVD, GI problems
or psychiatric disorders
Drug interaction with
CYP3A4 or P-glycoprotein
inhibitors.
Warning in patients with
hematologic, renal, and
hepatic insufficiency
Location in GHS
Zone 1,2, 3 + Trauma
Zone 1,2, 3 + Trauma
Main Inpatient Pharmacy
Zone 1,2, 3 + Trauma

Author, year
Design/
sample size
Intervention & Comparison
Outcome
Zhang, 2014
Observation
al, n=60
IM betamethasone 7 mg x 1
vs
diclofenac 75 mg BID x 7 days
Betamethasone > diclofenac pain reduction at day 3
Betamethasone = diclofenac pain reduction at day 7
Betamethasone< diclofenac adverse effects
Daoussis, 2013
Observation
al, n=181
IM ACTH 100 units
78% of patients improved after one day after a dose
Minimal impact on blood pressure and serum
potassium
Elevation in fasting blood sugar for 24 hours
Terkeltaub, 2010
RCT, n=184
colchicine 1.8 mg total over 1 hour
vs
colchicine 4.8 mg total over 6 hours
vs
Placebo
Low-dose colchicine and high dose colchicine =
comparable efficacy
Low-dose colchicine safety profile = same as placebo
Man, 2007
RCT, n=90
prednisolone 30 mg/APAP 1g
vs
indomethacin 50 mg/APAP 1 g
Prednisolone/APAP is as effective as oral
indomethacin/acetaminophen in relieving pain but ↓
adverse effects.
Siegel, 1994
RCT, n=31
IM adrenocorticotropic hormone 40
IU
vs
IM triamcinolone acetonide 60 mg
Resolution of all symptoms occurred at an average of 8
days for both groups.
No adverse reactions were noted in either group
11 reinjections in the ACTH group vs 5 reinjections in the
triamcinolone acetonide group
Alloway, 1993
RCT, n=27
Indomethacin 50 mg TID
Vs
IM triamcinolone acetonide 60 mg
Resolution of all symptoms occurred at 8 days for a
patient taking indomethacin vs 7 days with
triamcinolone
Maccagno ,1991
RCT, n=61
etodolac 300 mg BID x 7 days
vs
naproxen 500 mg BID x 7 days
Significant in both treatment groups at each time
intervals
93-97% of patients report improved condition treated
with either agent

1.
Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from http://www.micromedexsolutions.com/
2.
Khanna D, et al. 2012 American College of Rheumatology guidelines for the management of gout. Arthritis Care Res 2012;64:1447-1461.
3.
Wilson L, et al. Pharmacotherapy. 2016 Aug;36(8):906-22
4.
Daoussis D, et al. Joint Bone Spine. 2013 May;80(3):291-4.
5.
Terkeltaub RA, et al. Arthritis Rheum. 2010 Apr;62(4):1060-8
6.
Man CY, et al. Ann Emerg Med. 2007 May;49(5):670-7.
7.
Siegel LB, et al. J Rheumatol. 1994 Jul;21(7):1325-7.
8.
Alloway JA, et al. J Rheumatol 1993; 20:111.
9.
Maccagno A, et al. Curr Med Res Opin. 1991;12(7):423-9.
Monotherapy
-NSAID
-Systemic
Corticosteroid
-Colchicine
Combination
Therapy
-Colchine + NSAID
-Colchicine+ Oral
Corticosteroid
-Intraarticular
steroid +oral
colchicine,
NSAID, or
corticosteroid
Elderly +/- Multiple
Comorbidities
-Corticosteroids >
NSAIDS
(particlarly
indomethacin) or
Colchicine
Renal insufficiency
-Intraarticular,
oral, or parenteral
glucocorticoids
NPO
-ACTH