• If there is no improvement in symptoms after 2–3 days:
• Review the diagnosis, check compliance with medication, and encourage self-care strategies.
• Increase the dose of medication to maximum and add paracetamol, with or without codeine.
• If there is still no improvement in symptoms in a confirmed case of gout, either:
• Try an alternative drug or consider combining treatment, or
• Seek specialist advice, especially if the person may be at risk of adverse effects.

• Most people with gout will respond within 2–3 days to a nonsteroidal anti-inflammatory drug (NSAID), colchicine, or oral prednisolone. If there is no improvement after this time, reviewing the diagnosis is necessary to exclude any other underlying pathology. See Differential diagnosis for more information.
• People should ideally be started on the maximum dose of medication, but if colchicine has been prescribed at a lower dose (to avoid adverse effects), consider increasing to the maximum tolerated dose.
• Always seek specialist advice if unsure about the next step if someone fails to respond to standard treatment. Switching to an alternative NSAID or colchicine may be worth trying, provided there are no contraindications.

These recommendations are based on published expert opinion, pragmatic advice and the 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 no evidence regarding switching medication or combining treatment when first-line drugs fail in acute gout. Nevertheless, if there are no contraindications, this may be an option. A survey of American Rheumatologists found that combining medication is common practice [Schlesinger et al, 2006b].
• People with gout are more likely to be elderly and have comorbidities, so are generally more vulnerable to drug adverse effects. If considering combining treatment, make a decision based on the risks and benefits.