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Gout attack: ice and paracetamol, then a nonsteroidal anti-inflammatory drug

The first-line treatment for a gout attack is paracetamol and the application of ice. If this fails, it is best to resort to a nonsteroidal anti-inflammatory drug such as ibuprofen.

A gout attack generally presents as inflammation of a joint (a reaction to the deposition of uric acid crystals), often the big toe, which rapidly becomes painful, hot, red, swollen and stiff.

Untreated, a gout attack lasts 3 to 10 days. There have been few comparative trials, so the evaluation of gout treatments is mainly based upon experience. The application of ice (30 mins, 4 times a day) relieves the pain of a gout attack. When the effect of ice and paracetamol is insufficient, a nonsteroidal anti-inflammatory should be offered, such as ibuprofen. Aspirin should be avoided.

Colchicine and corticosteroids should be offered as a second-line treatment. Colchicine has frequent, sometimes serious, adverse effects (destruction of blood cells, etc.). It has a narrow therapeutic margin and so caution should be used in prescribing it for patients taking several treatments, especially the elderly with kidney or liver disease.

Currently available treatments for gout attacks are not very satisfactory in terms of their adverse effects. Which may encourage patients to stick to their low-purine diets (no offal, no sardines, etc.).

©Prescrire November 2007

Source: "Traitement de la crise de goutte" Rev Prescrire 2007 ; 27 (289) : 848-849 - More articles in Prescrire's "Spotlight"...