Gout attacks: Pain relief

Photo of hands on a computer keyboard (PantherMedia / Robert Kneschke)

Gout attacks are one of the most painful joint problems. Anti-inflammatory painkillers and steroids can help relieve the pain. The gout medication colchicine is another option – but it has a slower effect.

Gout is caused by high uric acid levels. If the amount of uric acid in the body is too high, crystals may start to form in the joints and cause a painful gout attack. The pain and swelling are usually at their worst 6 to 12 hours after an attack starts. It usually takes about a week for the swelling to go down and the joint to recover. Acute pain can be relieved with anti-inflammatory painkillers or short-term steroid treatment. These medications start working within one hour.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Anti-inflammatory painkillers include drugs like diclofenac, ibuprofen, indomethacin, naproxen and etoricoxib. These drugs are also called non-steroidal anti-inflammatory drugs (NSAIDs). Some of them are available over the counter from pharmacies, while others are prescription-only. NSAIDs can effectively relieve the pain of a gout attack. Although acetylsalicylic acid (the drug in medicines like Aspirin) is an NSAID, it's not well suited for treating gout. On the contrary: Research suggests that taking a low dose of acetylsalicylic acid can increase the risk of a gout attack.

The most common side effects of NSAIDs include stomach and bowel problems such as diarrhea and nausea. Etoricoxib is somewhat better tolerated than other NSAIDs.

Peptic (stomach) ulcers are a rare side effect of NSAIDs. People who already have a higher risk of developing peptic ulcers can combine NSAIDs with drugs called proton-pump inhibitors (e.g. omeprazole). Proton-pump inhibitors protect the mucous lining of the stomach in order to help prevent ulcers.

Steroids (corticosteroids)

Steroids are typically taken in the form of tablets (oral steroids). Studies have shown that they are about as effective in relieving pain as NSAIDs are. Usually, the steroid prednisolone is used for five days at a dose of 3 to 4 tablets per day, each of which contain 10 mg of the active ingredient.

Prednisolone is better tolerated than most anti-inflammatory painkillers, especially by the stomach and bowel. One relatively rare side effect is a temporary rash.

Corticosteroid tablets have a bad reputation because they have serious side effects if you take them for a long period of time. But there’s no need to fear these side effects if you use them for the short-term treatment of a gout attack.

Colchicine

Colchicine is an herbal medication made from the autumn crocus plant. It is believed to stop immune cells that are involved in inflammations from entering the joints. Colchicine can effectively relieve acute gout. It's important to start the treatment within the first 36 hours of the gout attack.

Colchicine isn't used that much nowadays because it can take up to 24 hours to have its full effect. But it’s an alternative option for people who don't tolerate the other medications or who can't take them for other reasons.

Treatment with colchicine involves taking a total of four tablets that each have 0.5 mg of the drug in them. Two tablets are taken together first, and then the third tablet is taken after one hour. The fourth tablet is taken one hour after the third one. Most people tolerate this total colchicine dose of 2 mg well.

Medical societies advise people not to take higher doses of colchicine because it then very commonly leads to side effects such as diarrhea, nausea and vomiting. Also, according to what is currently known about the medication, higher doses aren't more effective. At any rate, it's important not to take more than the maximum daily dose of 6 mg.

Comparing the medications

Previous studies have shown the various medications to be equally effective. Gout attacks are typically treated with an NSAID such as naproxen or the steroid prednisolone. Depending on how severe the pain is, these two types of medication can be combined.

The choice of medication will also depend on your personal situation. NSAIDs, for example, are not suitable for people who are taking anticoagulants (anti-clotting medication) or who have stomach or bowel conditions, or kidney failure. Steroids may not be an option for people with diabetes or acute infections.