For an acute Gout attack, oral steroids and NSAIDs are comparable in efficacy. So choice depends on comorbidities: avoid steroids in diabetics or co-infection; avoid NSAIDs in those with peptic ulcer or cardiovascular disease history. If patient has neither, I would give both.
Even then with either, pain relief is barely 10% after 2 hours, and the attack takes on the average 5 days to resolve. If I were the patient, I’ll choose direct joint injection with steroid for the best quick fix.
Like I quipped in an earlier comment, I don’t believe in enduring unnecessary pain😁
After devoting over a week on the treatment of Gout, I wrap up with the first and only ACR guidelines on Gout treatment issued in 2012, summarised and simplified for public consumption.
A review is overdue, especially in light of recent understanding on the pivotal role of uric acid under-excretion in the pathogenesis of Gout, and the development of new uricosuric agents.
I would like to highlight 3 points in this summary article:…
1) Urate Lowering Therapies (ULT), like Allopurinol, should not be stopped during an acute attack. And it’s OK to start ULT at first presentation of an attack. Just treat the attack on its own merit;
2) Colchicine is less useful and less used these days for acute attacks, especially if the attack is over a day old. It should be used as prophylaxis against an attack when instituting ULT (to disrupt the mitotic spindle of neutrophils, preventing reaction to uric crystal dissolution), and should be maintained till uric acid target has been achieved for at least 3 months, visible tophi have resolved, and there is no clinically active inflammation;
3) Don’t treat half-heartedly. For chronic management, treat to target, serum uric acid <6mg/dl, <5.5mg/dl if tophaceous. For acute attack, use full dose NSAID/coxib and/or Prednisolone at least 0.5mg/kg body weight (if not 1mg/kg).