From the Guidelines
A comprehensive gout management plan should prioritize acute treatment with colchicine or an NSAID, and long-term prevention with allopurinol as the first-line urate-lowering therapy, starting at a low dose and titrating upwards to reach a target serum uric acid level below 6mg/dL. For acute gout attacks, colchicine 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve is effective if started within 24 hours of attack onset 1. Alternatively, an NSAID like naproxen 500mg twice daily or indomethacin 50mg three times daily for 3-5 days can be used. For patients with contraindications to these medications, oral prednisone 30-40mg daily for 3-5 days can be used.
Long-term Management
For long-term management, allopurinol is the preferred first-line urate-lowering therapy, starting at a low dose (≤100 mg/day) and gradually increasing by 100mg every 2-4 weeks until reaching a target serum uric acid level below 6mg/dL, with typical maintenance doses of 300-600mg daily 1. Febuxostat 40-80mg daily is an alternative for those who cannot tolerate allopurinol. Prophylactic low-dose colchicine (0.6mg daily) or NSAIDs should be used when initiating urate-lowering therapy for 3-6 months to prevent flares.
Lifestyle Modifications
Lifestyle modifications are also crucial, including:
- Weight loss if overweight
- Limiting alcohol (especially beer)
- Avoiding high-purine foods like organ meats and shellfish
- Staying well-hydrated
- Managing comorbidities like hypertension and diabetes This comprehensive approach addresses both the painful acute attacks and the underlying hyperuricemia that causes gout 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 with gout flares requiring repeated courses, consideration should be given to alternate therapy 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). Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis
The patient plan for gout should include:
- Monitoring for adverse effects of colchicine in patients with mild to moderate renal impairment
- Dose adjustment for patients with severe renal impairment, with a treatment course repeated no more than once every two weeks
- Alternate therapy for patients with gout flares requiring repeated courses
- Reduced dose for patients undergoing dialysis, with a total recommended dose of 0.6 mg (one tablet)
- Indomethacin as an effective treatment option for relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis 2 3
From the Research
Gout Patient Plan
- The treatment of gout involves the use of medications such as colchicine, which is approved for the treatment of acute gout flares and the prophylaxis of gout flares in patients aged >16 years 4.
- Colchicine works by inhibiting cytoskeletal microtubule polymerization, an important process in neutrophil functioning, and has been shown to be effective in reducing pain in patients with acute gout when given early 4, 5.
- The recommended dosage of colchicine for the treatment of acute gout flares is 1.2 mg at the first sign of the flare, followed by 0.6 mg in 1 hour, and has been shown to be well tolerated in patients with gout 4.
- In addition to colchicine, other medications such as NSAIDs, glucocorticoids, and urate-lowering therapies like allopurinol and febuxostat may be used to treat gout flares and lower serum urate levels 6.
- Initiating guideline-concordant gout treatment with colchicine and a urate-lowering xanthine oxidase inhibitor (XOI) has been shown to improve arterial function and reduce inflammation in patients with gout 7.
- However, the use of prophylactic colchicine for gout flare prevention is often not in line with guidelines, with a high prevalence of inappropriate use due to failure to prescribe concurrent urate-lowering therapies or adequately increase these medications 8.
Medication Management
- Colchicine is typically used at a dosage of 0.6 mg twice daily, or once daily for tolerance, and may be used in combination with other medications such as urate-lowering therapies 4, 7.
- Allopurinol is an agent of first choice for urate lowering therapy, but may require screening for HLA*B58:01 mutation in certain 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.
Lifestyle Modifications
- Lifestyle modifications, such as dietary changes and weight loss, may also be recommended as part of a comprehensive gout treatment plan, although the evidence for these modifications is not directly addressed in the provided studies.