• Prescribe a nonsteroidal anti-inflammatory drug (NSAID) such as diclofenac, indometacin, or naproxen as soon as possible, and continue the treatment until 48 hours after the attack has resolved.
• Co-prescribe a proton pump inhibitor (PPI) or misoprostol for gastric protection in people at risk of peptic ulcers, gastric bleeds, or perforations. For more information, see Preventing GI adverse effects in the CKS topic on NSAIDs - prescribing issues.
• If NSAIDs are contraindicated, not tolerated, or have been ineffective in previous attacks, prescribe oral colchicine 500 micrograms, two to four times a day, until relief of pain is achieved, or diarrhoea or vomiting occurs.
• If NSAIDs and colchicine are contraindicated, consider systemic corticosteroids.
• Use paracetamol, with or without codeine, in addition to other drug treatment, or alone, if NSAIDs, colchicine, and corticosteroids are all contraindicated.
• In people who are already established on allopurinol or febuxostat urate-lowering therapy, do not stop this during an acute attack of gout.

• Tailor the drug regimen to the individual. For some people with a high risk of adverse effects and mild symptoms, consider only self-care rather than any specific drug therapy.
• Diclofenac, indometacin, and naproxen are all fast acting nonsteroidal anti-inflammatory drugs (NSAIDs) with short half-lives, so clinical benefit will often be seen within a couple of days.
• See Management with no alarm features, taking NSAID in the CKS topic on Dyspepsia - unidentified cause for more information on whether or not to give gastroprotective medication in this scenario.
• Oral colchicine: lower doses are preferred to reduce the risk of adverse effects such as diarrhoea and vomiting.
• Corticosteroids can be given orally, intramuscularly, intravenously, or intra-articularly [Jordan et al, 2007]:
• Intra-articular corticosteroids are an option if the diagnosis is certain and only one or two (particularly large) joints are affected, and they are suitable for injecting, and the expertise to inject the joint is available. For more information, see the section on intra-articular corticosteroids.
• Ask the person to return if symptoms get worse, or if there is no improvement after 3–4 days. See Treatment failure for more information.

These recommendations are based on a guideline produced by expert representatives of the British Society for Rheumatology (BSR). The evidence supporting the BSR recommendations is based on a systematic review of literature [Jordan et al, 2007]. There is little good quality evidence on the treatment of acute gout. Treatment needs to be based on patient preference and a balance of risk and benefits.

• Nonsteroidal anti-inflammatory drugs (NSAIDs): the evidence comes mainly from non-randomized controlled trials (non-RCTs) using indometacin. All NSAIDs appear equally effective. There is normally symptomatic relief within 24 hours, but CKS could find no head-to-head comparisons with colchicine [Underwood, 2006b].
• Of the cyclo-oxygenase-2 selective NSAIDs, only etoricoxib is licensed for the treatment of gout and there are trial data to support its effect [Schumacher et al, 2002; Rubin et al, 2004], but it may have a small increased risk of cardiovascular thrombotic events associated with its use [Aldington et al, 2005]. As people with gout may be at higher risk of cardiovascular disease, etoricoxib is best avoided.
• Diclofenac and naproxen are widely considered to have acceptable adverse effect profiles [CSM, 2002]. Indometacin has been studied more in gout than any other NSAID, and its safety profile is classed as intermediate risk of causing serious gastrointestinal (GI) adverse effects, although it is associated with more GI adverse events than naproxen or diclofenac.
• Ketoprofen, piroxicam, and sulindac are other standard NSAIDs that are licensed for the treatment of gout, but they are less frequently used and their adverse effect profiles are probably less favourable than diclofenac or naproxen.
• Ibuprofen and other standard NSAIDs not listed here are not licensed for the treatment of acute gout.
• Modified-release NSAIDs offer no additional benefit in terms of efficacy compared with standard preparations.
• Colchicine: the evidence comes from one small RCT (n = 43) showing the drug to be more effective than placebo, and more effective if taken in the first 24 hours. However, most people suffered adverse effects (diarrhoea and/or vomiting) with the higher dose of colchicine [Schlesinger et al, 2006a; Underwood, 2006b]. The BSR recommend lower doses of colchicine than that advised in the British National Formulary, to minimize the risk of adverse effects [Jordan et al, 2007].
• Systemic corticosteroids: the evidence from one small RCT (n = 90) shows that oral prednisolone (30 mg for 5 days) may be equally as effective as indometacin with fewer adverse effects [Man et al, 2007]. CKS could find no studies on the optimum dose and duration of corticosteroids but a short course of prednisolone 40 mg or less is relatively safe. Most people in case series reports respond in 24 hours with no adverse effects or rebound symptoms after stopping corticosteroids. In people with a monoarthritis, an intra-articular corticosteroid injection is highly effective in terminating an attack [Jordan et al, 2007].
• Analgesia: there is no trial evidence supporting the role of paracetamol or codeine in acute gout, but expert opinion and best practice suggests a role when symptoms are inadequately controlled using conventional measures.