What is the therapy and duration for acute and maintenance treatment of a patient with an acute gout (Gouty Arthritis) attack?

From the Guidelines

For an acute gout attack, treatment should begin with an anti-inflammatory medication as soon as possible, with first-line options including colchicine, NSAIDs, or corticosteroids, as recommended by the American College of Physicians 1. The choice of medication should be based on the presence of contraindications, the patient’s previous experience with treatments, and the number and type of joint(s) involved.

• Colchicine can be given at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, and then 0.5-0.6 mg daily until resolution, with a low-dose regimen preferred to minimize gastrointestinal adverse events 1.
• NSAIDs, such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily, can be used as an alternative.
• Corticosteroids, such as prednisone 30-40 mg daily, can also be used, especially in patients with contraindications to colchicine and NSAIDs. These medications should be continued until the acute attack resolves, typically 7-10 days. Ice and rest of the affected joint are also recommended. For maintenance therapy to prevent future attacks, patients should start with lifestyle modifications including:
• Weight loss if overweight
• Limiting alcohol intake
• Avoiding high-purine foods
• Staying well-hydrated If the patient has frequent attacks (≥2 per year), elevated uric acid levels, tophi, or evidence of joint damage, urate-lowering therapy is indicated, with allopurinol typically started at 100 mg daily and gradually increased to achieve a serum uric acid level below 6 mg/dL, usually requiring 300-600 mg daily as a maintenance dose 1. Febuxostat (40-80 mg daily) is an alternative for those who cannot tolerate allopurinol. Urate-lowering therapy should be continued indefinitely, with prophylactic colchicine (0.6 mg once or twice daily) or low-dose NSAIDs often prescribed during the first 3-6 months to prevent flares that can occur as uric acid levels are decreasing 1.

From the FDA Drug Label

Acute gouty arthritis. Suggested Dosage: Indomethacin capsules 50 mg t.i.d. until pain is tolerable. The dose should then be rapidly reduced to complete cessation of the drug. The usual course of therapy is 7 to 14 days for acute painful shoulder (bursitis and/or tendinitis), but for acute gouty arthritis, the duration is until pain is tolerable, then the dose is reduced.

For acute gout attack therapy, the suggested dosage is indomethacin 50 mg t.i.d. until pain is tolerable, then the dose should be rapidly reduced to complete cessation of the drug. The duration of therapy for acute gouty arthritis is until pain is tolerable. For maintenance therapy,

• the dosage of allopurinol varies with the severity of the disease,
• the average is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout.
• The minimal effective dosage is 100 to 200 mg daily and the maximal recommended dosage is 800 mg daily.
• To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage 2 3.

From the Research

Acute Gout Attack Therapy

• The standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 4, 5, 6.
• NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks 6.
• Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use 6.
• Oral colchicine is effective, with low-dose colchicine demonstrating a comparable tolerability profile as placebo and a significantly lower side effect profile to high-dose colchicine 6.
• The IL-1β inhibitory antibody, canakinumab, is effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 6.

Maintenance Therapy

• Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy; the escalation of therapies until the target serum uric acid is reached 4, 7.
• Initial treatments include allopurinol and febuxostat, with uricosuric agents, probenecid, sulfinpyrazone, and benzbromarone, as adjuncts 4, 7.
• Allopurinol is an agent of first choice for urate lowering therapy, but screening for HLA*B58:01 mutation is recommended in Southeast Asian and Black populations to decrease the occurrence of allopurinol hypersensitivity syndrome 5.
• Febuxostat is another efficacious urate lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety 5.

Duration of Therapy

• The duration of acute gout attack therapy is not specified in the provided studies, but it is generally recommended to continue treatment until the acute attack has resolved 8, 6.
• The duration of maintenance therapy is long-term, with the goal of preventing future gout flares and achieving a target serum uric acid level 4, 7.