From the Guidelines
Gout treatment should prioritize urate-lowering therapy (ULT) with allopurinol as the first-line agent, along with lifestyle modifications and anti-inflammatory prophylaxis for acute attacks, as recommended by the 2020 American College of Rheumatology guideline 1.
Treatment Approach
For acute gout attacks, the following options are recommended:
- NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 7-10 days
- Colchicine (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily) started early
- Corticosteroids, either oral prednisone (30-40mg daily, tapered over 7-10 days) or joint injections, for those who can't take NSAIDs or colchicine
Long-term Management
- Lifestyle modifications:
- Limiting alcohol (especially beer)
- Reducing intake of purine-rich foods like red meat and seafood
- Maintaining healthy weight
- Staying hydrated
- Urate-lowering therapy with allopurinol (starting at 100mg daily, gradually increasing to 300-600mg) as the most common medication
- Febuxostat (40-80mg daily) as an alternative for those who can't tolerate allopurinol
Key Recommendations
- Initiate ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 1
- Use a low starting dose of allopurinol (≤100 mg/day, and lower in patients with CKD) or febuxostat (≤40 mg/day) with subsequent dose titration to target 1
- Continue anti-inflammatory prophylaxis for 3-6 months after initiating ULT 1
From the FDA Drug Label
For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine However, in patients with severe impairment, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks. For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet).
The treatment for gout involves the use of colchicine.
- For patients with mild to moderate renal impairment, no dose adjustment is required, but close monitoring for adverse effects is necessary.
- For patients with severe renal impairment, the treatment course should not be repeated more than once every two weeks.
- For patients undergoing dialysis, the recommended dose is a single dose of 0.6 mg. 2
From the Research
Treatment Options for Gout
- The treatment of gout involves managing acute inflammatory attacks and lowering serum urate levels to prevent disease progression 3.
- Options for treating acute gout attacks include NSAIDs, colchicine, corticosteroids, adrenocorticotropic hormone (ACTH), and intra-articular corticosteroids 3, 4.
- Prophylaxis should be considered an adjunct to long-term urate-lowering therapy, with the optimal agent, dose, and duration for gout prophylaxis requiring further investigation 3.
Urate-Lowering Therapy
- Allopurinol and benzbromarone are cornerstone drugs for reducing serum urate levels, with febuxostat and pegloticase helping to optimize control of serum urate levels, especially in severe cases 3, 5.
- Other agents, such as fenofibrate and losartan, may be helpful as adjuvant drugs 3.
- Novel uricosurics, including verinurad and arhalofenate, are being developed as potential treatments for gout 5.
Acute Gout Treatment
- NSAIDs and COX-2 inhibitors are effective agents for treating acute gout attacks, with systemic corticosteroids having similar efficacy to therapeutic doses of NSAIDs 4.
- Oral colchicine has been shown to be effective, with low-dose colchicine demonstrating a comparable tolerability profile to placebo and a significantly lower side effect profile to high-dose colchicine 4.
- The IL-1β inhibitory antibody, canakinumab, has been effective for treating acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 4, 5.