Hi, d_q, nice to see more interesting questions.
The thing about my three-pronged gout pain attack plan is that it’s mine. Because, if there is only one thing you are ever allowed to remember about gout treatment it’s: “Treat To Individual Target”. So, my personal plan is actually at Acute Gout Attack Treatment Plan. But, there are many individual points to discuss how that would apply to anyone else.
Therefore, I don’t want to post it as a “quickly accessible thread”. Because I feel it should be a slowly ingested example of a plan. Then, other gout patients can inspect each point to see how it applies to them. Unfortunately, that’s a longwinded process. So, doctors have to rely on standards that have served them through their careers. Because sometimes you have to accept “average” treatment if there are only 10-15 minutes available.
Otherwise, nothing would ever get prescribed. But in this gout forum, we can guide patients through the process.
Firstly, we have to understand individual attitudes to pain. Because pains that might be tolerated by one person will put another in bed. This is important because, in my experience, immobility tends to extend the duration of a gout flare. But, I have not yet found science to support this in the general gout population.
Next, we consider each of the points:
1. Inhibit Inflammation.
2. Reduce Inflammation.
3. Block Residual Pain.
1. Colchicine. To answer your initial question, I’d suggest one colchicine at night. Then another in the morning, as required. But, that might not fit an individual’s lifestyle. Also, there’s evidence to suggest it’s not always the most appropriate dose. So, at best it’s a starting point for a discussion between doctor and patient. Ultimately, all I’m really trying to do is support gout patients so they ask the right questions and understand their doctor’s responses.
On the other hand, colchicine might be totally inappropriate for some patients. Because it suppresses the immune system. So, depending on personal circumstances it can be a very bad idea.
2. We can see here, there are opposing views on NSAIDs and steroids. Some think that the immunosuppressive nature of drugs like methylprednisolone, methylprednisone, and corticosterone can support or replace colchicine for gout. Others, like me, would never consider them. In any case, we cannot give general guidance for specific NSAID choice or dosing. Because that’s the doctor’s job.
Anyway, all NSAIDs are medically similar. So, most doctors will just prescribe the one they are most used to. Then, if a patient doesn’t get on with it, they might try a different one. For example, ibuprofen, naproxen, and indomethacin are common choices. But even though one might seem better tolerated than another, they all have bad cardiac risks after long periods of high doses.
3. I’ve heard 2 arguments about paracetamol dosing as an addition to NSAIDs. I was taught to intersperse the dose. That is, NSAID at every 4 hours starting at zero hours. With paracetamol every 4 hours starting after 2 hours.
But a friend, whose extreme pain experiences are different from mine, recommends taking them together. “Because they work differently, so provide more pain relief when taken at the same time”. Anyway, I think this goes back to being mindful about your pain symptoms, and the effects of treatment. Then, you can adjust dosing to suit your situation.
Always remember, doctors will suggest dose intervals based on average half-life and other factors. But, within drug safety limits, there is a great deal of flexibility.
To summarize, I hope you can see why doctors often prescribe a “one-size-fits-all” treatment plan. Because they simply do not have time to discuss all these different aspects. Also, in most cases, the patient gets the pain relief they want. So, it’s only worth discussing individual cases when there is a specific problem. In that case, the starting point is almost certainly different from my Acute Gout Attack Treatment Plan. And, the problems are always unique.
Finally, to answer your question “someone gets an acute flare today; what would be your dosing to hit hard?”
Dear Someone (related to nobody?),
Ask your doctor if the following is safe given your medical history:
1. Take 2 colchicine immediately (for 0.5mg or 0.6mg pills) with the maximum dose of ibuprofen. Try to keep affected joint moving.
2. At 2 hours, if symptoms persist, take another colchicine with maximum dose paracetamol (acetaminophen). Try harder to keep affected joint moving.
3. At 4-5 hours, repeat ibuprofen. Are you really trying to keep moving? Note that I’ve considered increasing the interval if symptoms are more tolerable. Sometimes I consider reducing the dose.
4. At 6-8 hours, repeat paracetamol. Accept you’re a wimp when it comes to pain tolerance.
If your doctor is concerned about any aspect of this emergency gout flare treatment, let’s discuss how we can improve it just for you.
Yours with love, tolerance, and patience.
I wonder if anyone kept reading long enough to read the final answer?