From the Guidelines
The recommended workup for gout begins with joint aspiration to identify monosodium urate crystals, which is the gold standard for diagnosis, as stated in the 2020 American College of Rheumatology guideline for the management of gout 1. This should be accompanied by serum uric acid measurement, though levels may be normal during acute attacks. Additional laboratory tests include:
- Complete blood count
- Renal function
- Inflammatory markers For acute gout treatment,
- NSAIDs like indomethacin (50mg three times daily for 3-5 days) are first-line therapy
- Colchicine (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until resolution) is effective if started within 24 hours of symptom onset, as recommended by the American College of Physicians 1
- Corticosteroids, either oral prednisone (30-40mg daily for 3-5 days with taper) or intra-articular injection, are alternatives for patients with contraindications to NSAIDs or colchicine For long-term management,
- Urate-lowering therapy is indicated for patients with recurrent attacks, tophi, joint damage, or kidney stones
- Allopurinol (starting at 100mg daily, gradually increasing to achieve target uric acid <6 mg/dL) is the preferred first-line agent, with febuxostat as an alternative, as recommended in the 2020 American College of Rheumatology guideline for the management of gout 1 Prophylaxis with low-dose colchicine (0.6mg daily) or NSAIDs should be initiated concurrently with urate-lowering therapy for 3-6 months to prevent flares. Lifestyle modifications including:
- Weight loss
- Limiting alcohol (especially beer)
- Reducing purine-rich foods
- Avoiding fructose-sweetened beverages are important adjuncts to pharmacologic therapy, as recommended by the European League Against Rheumatism (EULAR) 1. These treatments target the underlying pathophysiology of gout, which involves hyperuricemia leading to crystal deposition in joints, triggering inflammatory cascades that cause the characteristic painful arthritis.
From the FDA Drug Label
The recommended dosage of Colchicine Tablets, USP for prophylaxis of gout flares for adults and adolescents older than 16 years of age is 0.6 mg once or twice daily. The maximum recommended dose for prophylaxis of gout flares is 1.2 mg/day. The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later.
The recommended workup and treatment for gout includes:
- Prophylaxis of gout flares: 0.6 mg of colchicine once or twice daily, with a maximum dose of 1.2 mg/day.
- Treatment of gout flares: 1.2 mg of colchicine at the first sign of the flare, followed by 0.6 mg one hour later. Key considerations:
- Dose adjustments may be necessary in patients with renal or hepatic impairment.
- Patients should be monitored closely for adverse effects of colchicine.
- Alternate therapy should be considered in patients requiring repeated courses of treatment for gout flares 2.
From the Research
Gout Workup and Treatment
The recommended workup and treatment for gout involve a combination of non-pharmacological and pharmacological approaches.
- Diagnosis is typically made based on clinical presentation, laboratory tests, and sometimes arthrocentesis to confirm the presence of urate crystals.
- Non-pharmacological approaches include lifestyle modifications such as diet, weight loss, and avoidance of alcohol and purine-rich foods.
Pharmacological Treatment
Pharmacological treatment for gout can be divided into two main categories:
- Treatment of acute gout attacks:
- Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout attacks, but caution is required due to potential adverse effects, especially in the elderly 3.
- Colchicine is another effective option for treating acute gout, but monitoring for toxicity is necessary 4, 3.
- Corticosteroids can also be used to treat acute gout, either orally or intra-articularly 3.
- Urate-lowering therapy:
- Allopurinol is a commonly used urate-lowering therapy, and its dosage should be tailored according to renal function to minimize toxicity 4, 3.
- Febuxostat is another xanthine oxidase inhibitor that is clinically equivalent to allopurinol 4.
- Uricosuric drugs, such as probenecid, can increase uric acid excretion and are an alternative option for patients who do not respond to other treatments 4, 3.
Treatment Patterns and Adjustments
Real-world treatment patterns for gout patients show a substantial number of distinct treatment patterns and frequent treatment adjustments by physicians 5.
- A study found that 60.8% of patients in the colchicine cohort were prescribed colchicine consistently from the emergency room/acute care facility visit to the first follow-up visit, while 26.8% and 17.7% of patients in the other cohort were prescribed NSAIDs and systemic corticosteroids consistently, respectively 5.
- Treatment adjustments were made in 27.0% of treated patients, with the most common reasons being inadequacy of treatment for maintenance therapy, insufficient dosage, or inadequate response 5.
Opportunities for Improvement
Despite the availability of effective treatments, gout management remains suboptimal, with opportunities for improvement in diagnostic accuracy, patient education, and adherence to treatment recommendations 6, 7.