What is the treatment for gouty arthritis?

From the Guidelines

Gout arthritis should be treated with a combination of urate-lowering therapy (ULT) and anti-inflammatory medications, with a strong recommendation for initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares. The treatment approach involves both immediate pain relief and long-term management. For acute gout attacks, medications such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or glucocorticoids are strongly recommended 1. When initiating ULT, concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months is strongly recommended 1. Some key points to consider in the treatment of gout arthritis include:

• Initiation of ULT with allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage ≥3) 1
• Using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (≤40 mg/day) 1
• A treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl 1
• Lifestyle changes, such as maintaining a healthy weight, limiting alcohol consumption, avoiding high-purine foods, and drinking plenty of water, are also crucial in managing gout arthritis. It is essential to continue ULT medications indefinitely and start them during a symptom-free period, often with colchicine prophylaxis (0.6mg daily) for the first 3-6 months to prevent flares 1.

From the FDA Drug Label

Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis ILARIS is indicated for the symptomatic treatment of adult patients with gout flares in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate. Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis.

Treatment options for gout arthritis:

• Indomethacin (PO): can be used to relieve the pain, reduce the fever, swelling, redness, and tenderness of acute gouty arthritis 2.
• Canakinumab (SQ): can be used for the symptomatic treatment of adult patients with gout flares in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate 3.
• Probenecid (PO): can be used for the treatment of the hyperuricemia associated with gout and gouty arthritis 4.

From the Research

Treatment Options for Gout Arthritis

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective agents for the treatment of acute gout attacks 5
• Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use 5
• 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 5
• Interleukin-1 (IL-1) inhibitors, such as canakinumab, are effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 5

Prevention of Recurrent Gout

• Xanthine oxidase inhibitor therapy, such as allopurinol, remains the consensus first-line treatment option for the prevention of recurrent gout 6
• Add-on therapies that reduce serum urate concentration include traditional uricosuric agents and a novel uric acid reabsorption inhibitor 6
• Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating any urate-lowering therapy in order to prevent acute gouty arthritis for a period of at least 6 months 6

Safety Concerns of Gout Treatment

• Gout is a curable disease with appropriate treatment, but clinicians should be aware of some of the safety concerns of medications used to treat acute and chronic gout 7
• The benefits of gout drugs usually outweigh their safety concerns, but studies are needed in gout patients with chronic kidney disease and/or cardiovascular disease to better understand gout treatment safety issues 7

Emerging Therapies for Gout

• Novel therapies, such as IL-1β antagonists, are highly effective for arresting flares but their cost-effectiveness renders them salvage therapies 8
• Allopurinol is an agent of first choice for urate lowering therapy, but screening for HLA*B58:01 mutation is a cost-effective approach to decrease the occurrence of allopurinol hypersensitivity syndrome in certain populations 8
• Febuxostat is another efficacious urate lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety 8