Arthritis Treatment: How to Treat an Acute Attack of Gouty Arthritis

Gout is a type of arthritis due to the accumulation of uric acid (UA) crystals in body tissues. This accumulation is due to either an abnormal increased production of uric acid or to inability to excrete uric acid through the kidneys quickly enough.

Over time, as uric acid levels slowly rise, these crystals can accumulate in a number of areas, particularly the joints and the kidneys.

An attack of gouty arthritis is usually the first sign of gout. These attacks may occur in almost any joint but are most common in the toes, the insteps, and the ankles.

The attacks are characterized by severe pain, swelling, redness, heat, and disability. The pain has been described as being so intense that even the weight of a bed sheet is unbearable.

The goal of treatment of a gout attack is to reduce the severity of the attack, relieve pain, and minimize the amount of incapacity a patient is dealing with.

There are three categories of medicines used to treat an acute attack of gouty arthritis. The first group is the non-steroidal-anti-inflammatory drugs (NSAIDS). They are used by many rheumatologists with reasonably good effectiveness. However, their efficacy is limited by their potential toxicity including gastrointestinal, kidney, and cardiovascular.

These potential toxicities need to be taken into account since most patients with gout have other disease conditions such as chronic kidney disease, high blood pressure, heart disease, elevated blood lipids, and obesity.

Colchicine is another type of drug that is used to head off acute attacks during the first 24 hours. It used to be available as a cheap generic drug but is now only available as a n expensive brand name preparation called Colchrys. It is effective but must be used within the first 24 hours of onset of an attack to be effective. Colchrys also has toxicities associated with its use. It can lead to abdominal cramps and diarrhea which leads to dehydration and to worsening of gout.

Glucocorticoids- steroids- are the third category of drug used to treat acute attacks. Steroids can be given either orally starting with a dose of 30 mgs of prednisone or its equivalent as a single morning dose with a slow taper or as an injection into a joint if the attack is limited to a single joint. The advantage to injection is that it also allows for withdrawal of fluid from the joint which is helpful in confirming diagnosis.

Use of local anesthetic along with ultrasound needle guidance makes this procedure relatively painless.
The use of steroids must be tempered with the thought that many patients with gout also have diabetes and they should be counseled that their blood sugars may rise temporarily.

A new drug in development is canakinumab, a biologic drug that blocks interleukin 1. It is very effective for attacks but is also extremely expensive. IL-1 TRAP is another drug that blocks the effects of interleukin-1 and is also in the investigative phase of drug discovery.