From the Guidelines
Gout treatment should prioritize allopurinol as the first-line urate-lowering therapy (ULT), with a starting dose of less than 100 mg/day, and subsequent dose titration to target serum uric acid levels below 6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline 1. For acute gout attacks, treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen or indomethacin, colchicine, and corticosteroids like prednisone.
- NSAIDs are typically used for 7-10 days
- Colchicine is effective when started early, with a dose of 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve
- Corticosteroids like prednisone may be used for patients who cannot take NSAIDs or colchicine, with a dose of 30-40mg daily, tapered over 7-10 days. For long-term management, lifestyle modifications are important, including:
- Limiting alcohol, especially beer
- Reducing intake of purine-rich foods like red meat and seafood
- Maintaining a healthy weight
- Staying hydrated Medications to lower uric acid levels, such as allopurinol or febuxostat, should be continued indefinitely once started, with the goal of preventing future attacks by reducing uric acid production or increasing its excretion, addressing the underlying cause of gout—high uric acid levels that form painful crystal deposits in joints, as supported by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Long-term therapy should typically begin after the acute attack has resolved, and patients may need prophylactic colchicine (0.6mg daily) during the first few months of urate-lowering therapy to prevent flares, as recommended by the 2020 American College of Rheumatology guideline 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).
The treatment options for gout include:
- Colchicine for the treatment of gout flares
- Dose adjustment may be necessary in patients with renal or hepatic impairment
- Alternate therapy should be considered in patients with severe impairment or those requiring repeated courses of treatment 2
- Monitoring for adverse effects is recommended in all patients, especially those with renal or hepatic impairment 2
From the Research
Treatment Options for Gout
The treatment options for gout can be categorized into two main areas:
- the management of acute gout attacks
- and the prevention of future attacks through urate-lowering therapy.
Management of Acute Gout Attacks
For the management of acute gout attacks, the following options are available:
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Colchicine
- Corticosteroids
- IL-1 inhibitors for flare refractory to standard therapies 3, 4. These options are equally efficacious, and the choice of treatment is guided by comorbidities 5.
Urate-Lowering Therapy
Urate-lowering therapy aims to prevent gout flares and includes:
- Xanthine oxidase inhibitors such as allopurinol and febuxostat
- Uricosuric agents such as probenecid, sulfinpyrazone, and benzbromarone
- Novel uricosurics such as verinurad and arhalofenate 3, 4. The goal of urate-lowering therapy is to achieve a target serum uric acid level, and treatment should be escalated until this target is reached 3.
Special Considerations
In certain populations, such as those with chronic kidney disease or ischemic heart disease, treatment may need to be personalized to take into account comorbidities 3, 4. Additionally, patients with refractory gout may require alternative treatment options, such as lesinurad in combination with xanthine oxidase inhibitors or pegloticase 4, 6.