Drug

Dose

Drugs for Treatment of Acute Gout

NSAIDs" Fenoprofen Flurbiprofen

Ibuprofen Indometacin"

Indometacin* Ketoprofen

Meclofenamate

Naproxen*

Piroxicam Sulindac* Tolmetin

800 mg po eve'y 6 hours

100 mg po four times a day for 1 day, then 50 my jxj fuui times c\ day 600-800 mg po four times a day 150-200 mg po daily (in 3 divided doses) for 3 days, then 100 mg po daily (in 2 divided doses) for 4-7 days 50 mg po three times a day 50 mg po four times a day or 75 mg po three times a day 100 mg po three times a day to four times a day 1,000 mg daily x 3 days, then 500 mg daily x 7 days or 750 mg po initially, then 250 mg oo every 8 hours 40 mg po once daily 200 mg two times a day x 7-10 days 400 mg po three times a day to four times a day

Celecoxib Meloxicam Colchicine

Colcrys* (colchicine)

Local corticosteroids: Met hy I predni so lone (example) Systemic corticosteroids: Prednisone (example) Triamcinolone acetonide

200 mg po two times a day 7.S-15 mg po once daily 0.6 mg po every hour for up to 3 doses, then 0.6 mg 1-2 x daily if desired before antihyseruricemic therapy is started; may occasionally use in low doses for prophylaxis 1.2 mg po at the onset of attack, then 0.6 mg 1 hou' later 10-40 mg x 1 dose by intra-articular injection

40-60 mg po once daily x 3 days, then decrease by 10 mg every 3 days

60 mg x 1 dose by IM injection

Antihyperuricemic Treatment

Allopurinol Starting dose: CrCI greater than 90

mL/min = 300 mg po daily

CrCI 60-90 mL/min = 200 mg po daily

CrCI 30-60 mL/min = 100 mg po daily

CrCI less than 30 mL/min = 50 mg po daily Adjust dosage Dased on follow-up uric acid levels; maximum 800 mg po daily

Febuxosta t* Stodrting dose 40 m g era I ly once daily;

increase to 80 rng once daily if serum uric add does not decline to 6.0 mg/dL or lower after 1 weeks of treatment Probenecid StSrtinc} do$e 250 rtig po two times a day; may increase to 1.000 mg po two times a day

CrCl, creatinine clearance; IM, intramuscular; NSAlDs, nonsteroidal anti-Inflammatory drugs,

■^Drugi thiat are FDA approved for treatment of gout are Indicated with an asterisk.

Adapted with permission from Ref. 9. Copyright 2003 Massachusetts Medical Society. All rights reserved. Drug regimens derived from various sources.

In July 2009, the FDA approved Colcrys, a single-ingredient colchicine product for treatment of acute gout attacks. As part of the approval process, a dosing study showed that one dose initially and a single additional dose after 1 hour was just as effective and less toxic than continued hourly colchicine dosing. As a result, the approved dosage regimen is 1.2 mg (two 0.6-mg tablets) at the onset of an acute flare, followed by 0.6 mg 1 hour later.

Corticosteroids

When only one or two joints are affected, intra-articular corticosteroid injection can provide rapid relief with a relatively low incidence of side effects. Joint fluid obtained by arthrocentesis should be examined for evidence of joint space infection and crystal identification. If uric acid crystals are present and there is no infection, intra-artic-ular injection can proceed.

Systemic corticosteroids are a useful option in patients with contraindications to NSAIDs or colchicine (primarily renal impairment) or polyarticular attacks, especially in elderly patients. A single intramuscular injection of a long-acting corticosteroid such as triamcinolone hexacetonide may be used. Oral agents may be needed, es pecially for severe attacks. Prednisone 40 to 60 mg (or an equivalent dose of another agent) is given daily, with a gradual taper over 2 weeks. A recent study found that oral methylprednisolone and naproxen are equivalent in treating acute gout attacks.19'20

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