What are the management options for gout (gouty arthritis)?

From the Guidelines

The management of gout should prioritize a treat-to-target approach with urate-lowering therapy (ULT), lifestyle modifications, and anti-inflammatory prophylaxis, as recommended by the 2020 American College of Rheumatology guideline 1.

Key Recommendations

• For acute gout attacks, treatment options include NSAIDs, colchicine, or corticosteroids, with the choice depending on patient-specific factors and comorbidities.
• Allopurinol is the preferred first-line ULT, starting at a low dose (≤100 mg/day) and titrating to achieve a serum urate target of <6 mg/dL 1.
• Lifestyle modifications are essential for long-term management, including maintaining a healthy weight, limiting purine-rich foods, reducing alcohol intake, and staying well-hydrated.
• When initiating ULT, concomitant anti-inflammatory prophylaxis therapy (e.g., low-dose colchicine or an NSAID) should be used for at least 3-6 months to prevent flares 1.

Treatment Approach

• For patients with frequent gout attacks, tophi, joint damage, or kidney stones, ULT is indicated, with allopurinol as the first-line option.
• Febuxostat (≤40 mg/day) is an alternative for patients who cannot tolerate allopurinol.
• The goal of ULT is to achieve a serum urate level of <6 mg/dL, with regular monitoring and dose adjustments as needed 1.

Additional Considerations

• Patient education and shared decision-making are crucial in managing gout, with discussions on benefits, harms, costs, and individual preferences 1.
• A comprehensive approach to gout management should prioritize both symptom relief and the underlying hyperuricemia that causes gout.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels 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 tablets (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.

The management of gout involves the use of allopurinol with the following key points:

• The dosage of allopurinol varies with the severity of the disease, with an average of 200 to 300 mg/day for mild gout and 400 to 600 mg/day for 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 to start with a low dose of 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.
• Colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases 2.
• Indomethacin can be used to relieve the pain, fever, swelling, redness, and tenderness of acute gouty arthritis 3.

From the Research

Management of Gout

• Gout is a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within synovium of joints, leading to severe pain and reduced quality of life for patients 4, 5.
• The treatment of gout includes both acute flares and urate-lowering therapy, with a focus on a treat-to-target strategy to prevent gout flares 4, 5.
• 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.
• Urate-lowering therapies aim to prevent gout flares, with initial treatments including allopurinol and febuxostat, and uricosuric agents such as probenecid, sulfinpyrazone, and benzbromarone as adjuncts 4, 5, 6.
• Emerging therapies are also being developed, and there is an increasing personalization of treatment, adjusting pharmacotherapy depending on comorbidities and patient preference 4, 5.
• The efficacy and safety of allopurinol, febuxostat, benzbromarone, and probenecid in gout have been supported by moderate quality data, while pegloticase is associated with more withdrawals due to adverse events and infusion reactions 6.

Urate-Lowering Therapy

• Urate-lowering therapy is a key component of gout management, with the goal of reducing serum urate levels to prevent gout flares 4, 5, 6.
• Xanthine oxidase inhibitors such as allopurinol and febuxostat, uricosuric medications such as benzbromarone and probenecid, and uricases such as pegloticase are commonly used urate-lowering therapies 6.
• The choice of urate-lowering therapy depends on various factors, including patient comorbidities, kidney function, and tolerance to side effects 4, 5.

Acute Gout Flares

• Acute gout flares are a common symptom of gout, and can be treated with anti-inflammatory medications such as NSAIDs, colchicine, and corticosteroids 4, 5.
• IL-1 inhibitors are also an option for flare refractory to standard therapies 4.
• The treatment of acute gout flares aims to reduce pain and inflammation, and prevent future flares 4, 5.