From the Guidelines
To treat gout, initiate urate-lowering therapy (ULT) with allopurinol as the preferred first-line treatment, starting with a low dose of 100 mg/day or less, and titrate to achieve a target serum urate level of <6 mg/dl, while also providing anti-inflammatory prophylaxis for at least 3-6 months. This approach is based on the most recent and highest quality evidence from the 2020 American College of Rheumatology guideline for the management of gout 1. For acute gout attacks, options include colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or glucocorticoids, with colchicine being effective when taken early in the attack 1.
Key Considerations
- Allopurinol is the preferred first-line ULT, even for patients with moderate-to-severe chronic kidney disease (CKD), with a starting dose of 100 mg/day or less 1.
- Febuxostat is an alternative ULT option, starting at a dose of 40 mg/day or less 1.
- Lifestyle changes, such as limiting alcohol intake, reducing purine-rich foods, maintaining a healthy weight, and staying hydrated, are crucial for managing gout 1.
- Treatment should be ongoing even after symptoms resolve to prevent future attacks and joint damage.
Management of Acute Attacks
- Colchicine (1.2mg followed by 0.6mg one hour later) is effective for acute gout attacks when taken early 1.
- NSAIDs, such as naproxen or indomethacin, can be used to treat acute attacks, but their use should be guided by the patient's medical history and current health status 1.
- Glucocorticoids, including oral, intraarticular, or intramuscular administration, are also options for managing acute gout attacks 1.
From the FDA Drug Label
Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis. Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis For prophylaxis of gout flares in patients with mild (estimated creatinine clearance 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.
Treatment Options for Gout:
- Probenecid: used to treat hyperuricemia associated with gout and gouty arthritis 2
- Indomethacin: effective in relieving pain, reducing fever, swelling, redness, and tenderness of acute gouty arthritis 3
- Colchicine: used for prophylaxis of gout flares, with dose adjustments recommended for patients with renal impairment 4
From the Research
Treatment Options for Gout
- 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 5, 6
- Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy, and include allopurinol, febuxostat, and uricosuric agents such as probenecid, sulfinpyrazone, and benzbromarone 5, 6, 7
- Lifestyle modifications also form a part of gout prevention 6
Acute Gout Treatment
- NSAIDs, colchicine, and glucocorticoids are first-line agents for gout flares 6
- IL-1β antagonists are highly effective for arresting flares but are considered salvage therapies due to their cost-effectiveness 6
- NSAIDs are not significantly associated with a difference in pain reduction compared with cyclooxygenase inhibitors and glucocorticoids for treating acute gout, but are associated with higher rates of adverse events and withdrawal due to adverse events 8
Urate-Lowering Therapy
- 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 6
- Febuxostat is another efficacious urate-lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety 6
- Novel uricosurics, such as verinurad and arhalofenate, are agents with future promise 6
- Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity threatens the achievement of sustained urate-lowering responses 6, 7