From the Guidelines
Gout management should prioritize urate-lowering therapy (ULT) with allopurinol as the preferred first-line treatment, starting with a low dose of ≤100 mg/day, and titrating to achieve a target serum urate level of <6 mg/dl. This approach is supported by the 2020 American College of Rheumatology guideline for the management of gout 1. For acute gout attacks, treatment options include colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or glucocorticoids, with colchicine recommended at a dose of 1.2mg at the first sign of attack, followed by 0.6mg one hour later, and then 0.6mg once or twice daily until symptoms resolve 1.
When initiating ULT, concomitant anti-inflammatory prophylaxis therapy is strongly recommended for a duration of at least 3-6 months to prevent gout flares 1. Lifestyle modifications are also crucial in managing gout, including maintaining a healthy weight, limiting alcohol consumption (especially beer), avoiding high-purine foods like organ meats and shellfish, and staying well-hydrated.
Key considerations in gout management include:
- Initiating ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 1
- Using a treat-to-target management strategy with ULT dose titration guided by serial serum urate measurements 1
- Applying ice to the affected joint for 20-30 minutes several times daily and elevating the limb to reduce swelling
- Resting the joint and drinking plenty of water to help manage acute gout attacks.
Overall, a comprehensive approach to gout management that incorporates ULT, lifestyle modifications, and anti-inflammatory prophylaxis can help reduce the frequency and severity of gout attacks, improve quality of life, and prevent long-term joint damage 1.
From the FDA Drug Label
Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis. The treatment of gout can be managed with probenecid, which is indicated for the treatment of hyperuricemia associated with gout and gouty arthritis 2.
- Key points:
- Probenecid is used to treat hyperuricemia associated with gout and gouty arthritis.
- It can be used as an adjuvant to therapy with certain antibiotics. Colchicine is also used for the treatment of gout flares and prophylaxis of gout flares, with specific dosing recommendations for patients with renal or hepatic impairment 3 3.
- Important considerations:
- Dose adjustment may be necessary in patients with renal or hepatic impairment.
- Patients should be monitored closely for adverse effects of colchicine.
From the Research
Treatment Options for Gout
- Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout, with equal efficacy, and the choice of treatment is guided by comorbidities 4, 5.
- Allopurinol is an effective treatment for reducing concentrations of uric acid, with the starting dose guided by renal function and the maintenance dose guided by baseline serum uric acid concentration 5, 6.
- Febuxostat is another xanthine oxidase inhibitor, clinically equivalent to allopurinol, but has received a U.S. FDA black box warning for cardiovascular safety 6, 7.
- Uricosuric drugs, such as probenecid, increase uric acid excretion, and new drugs in this class are being developed 5, 7.
Pharmacotherapy 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 6, 7.
- Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy, and initial treatments include allopurinol and febuxostat 6, 7.
- Emerging therapies, such as novel uricosurics and pegloticase, are being developed for the treatment of gout, but their use is limited by factors such as cost-effectiveness and immunogenicity 7, 8.
Management of Gout
- Lifestyle modifications form a part of gout prevention, and management guidelines emphasize the importance of a therapeutic serum urate target for effective gout management 6, 8.
- Quality of care remains a major challenge in gout management, and strategies to ensure best practice require further focus to ensure that progress in pharmacotherapy translates into clinical benefit for people with gout 8.