What is the best treatment for gout?

From the Guidelines

The best treatment for gout involves a combination of lifestyle modifications, acute flare management with medications such as NSAIDs, colchicine, or corticosteroids, and long-term urate-lowering therapy (ULT) with allopurinol as the preferred first-line agent. For acute gout flares, NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) are first-line treatments, typically continued for 7-10 days 1. Colchicine is also effective when started early (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve) 1. For those who cannot take NSAIDs or colchicine, oral corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) may be used 1.

Key Considerations for Gout Management

• Lifestyle modifications are crucial, including:
  • Limiting alcohol (especially beer)
  • Reducing intake of purine-rich foods like red meat and seafood
  • Maintaining a healthy weight
  • Staying hydrated
• Urate-lowering therapy is recommended for patients with frequent attacks or complications, with allopurinol (starting at 100mg daily, gradually increasing to achieve target uric acid levels below 6mg/dL) being the most common medication 1.
• The choice of initial ULT should be based on patient factors, including kidney function, with allopurinol preferred for most patients but febuxostat considered for those with chronic kidney disease stage >3 1.
• Anti-inflammatory prophylaxis with colchicine, NSAIDs, or prednisone should be initiated when starting ULT and continued for 3-6 months to prevent flares 1.

Long-Term Management

For long-term management, the goal is to reduce uric acid levels to prevent crystal formation in joints. Allopurinol is recommended as the first-line ULT, with a starting dose of 100mg daily and gradual increase to achieve target uric acid levels below 6mg/dL 1. Regular monitoring of serum uric acid levels and adjustment of ULT as needed is crucial to achieve and maintain the target levels. Lifestyle modifications should be continued and reinforced as part of long-term management.

Recent Guidelines

Recent guidelines from the American College of Rheumatology (2020) strongly recommend allopurinol over other ULT as the preferred first-line agent for all patients, including those with chronic kidney disease stage >3, and support the use of low-dose colchicine for anti-inflammatory prophylaxis 1. These recommendations prioritize the reduction of morbidity, mortality, and improvement of quality of life for patients with gout.

From the FDA Drug Label

The evidence for the efficacy of colchicine in patients with chronic gout is derived from the published literature. Two randomized clinical trials assessed the efficacy of colchicine 0. 6 mg twice a day for the prophylaxis of gout flares in patients with gout initiating treatment with urate-lowering therapy. In both trials, treatment with colchicine decreased the frequency of gout flares.

The efficacy of a low-dosage regimen of oral colchicine (total dose 1. 8 mg over one hour) for treatment of gout flares was assessed in a multicenter, randomized, double-blind, placebo-controlled, parallel group, one week, dose-comparison study.

In patients with acute gout, a favorable response to naproxen was shown by significant clearing of inflammatory changes (e.g., decrease in swelling, heat) within 24 to 48 hours, as well as by relief of pain and tenderness.

The best treatment for gout is colchicine or naproxen, as both have been shown to be effective in reducing the frequency of gout flares and relieving pain and tenderness.

• Colchicine has been shown to decrease the frequency of gout flares in patients with chronic gout, with a low-dosage regimen of 1.8 mg over one hour being effective in treating gout flares 2.
• Naproxen has been shown to be effective in treating acute gout, with significant clearing of inflammatory changes and relief of pain and tenderness within 24 to 48 hours 3.

From the Research

Treatment Options for Gout

The treatment of gout involves managing acute gout flares and preventing future flares through urate-lowering therapy. The following are some of the treatment options available:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout flares 4, 5, 6.
• Colchicine is an effective treatment for acute gout flares, although it can have gastrointestinal side effects 7, 8, 4, 5, 6.
• Corticosteroids, such as oral or intramuscular injections, can be used to treat acute gout flares, especially in patients who cannot tolerate NSAIDs or colchicine 8, 4, 5, 6.
• Urate-lowering therapies, such as allopurinol and febuxostat, aim to prevent gout flares by reducing serum uric acid levels 4, 5, 6.
• Uricosuric agents, such as probenecid, can increase uric acid excretion and are used as adjuncts to other treatments 4, 5, 6.

Acute Gout Flare Treatment

For the treatment of acute gout flares, the following options are available:

• Colchicine (1.2 mg at the first sign of the flare, followed by 0.6 mg in 1 hour) was significantly more effective than placebo in treating acute gout flare, as assessed by the proportion of patients experiencing a >or=50% reduction in pain within 24 hours of initiating treatment 7.
• Colchicine is an effective treatment for the reduction of pain and clinical symptoms in patients experiencing acute attacks of gout, although its low benefit to toxicity ratio limits its usefulness as a first-line therapy 8.
• NSAIDs, colchicine, and corticosteroids are equally efficacious in treating acute gout flares, and the choice of treatment should be guided by comorbidities 6.

Urate-Lowering Therapy

Urate-lowering therapies aim to prevent gout flares by reducing serum uric acid levels. The following are some of the options available:

• Allopurinol is an effective treatment for reducing concentrations of uric acid, and the starting dose should be guided by renal function, while the maintenance dose should be guided by the baseline serum uric acid concentration 4, 6.
• Febuxostat is another xanthine oxidase inhibitor that is clinically equivalent to allopurinol 6.
• Uricosuric drugs, such as probenecid, increase uric acid excretion and can be used as adjuncts to other treatments 4, 6.