What is the care plan for managing gout?

From the Guidelines

The care plan for managing gout involves both immediate treatment of acute flares and long-term prevention strategies, with a focus on urate-lowering therapy (ULT) and lifestyle modifications to reduce morbidity, mortality, and improve quality of life. For acute gout attacks, treatment options include NSAIDs, colchicine, or corticosteroids, with the choice of drug based on the presence of contraindications, patient experience, and time of initiation after flare onset 1.

Key Recommendations

• Urate-lowering therapy (ULT) is recommended for patients with frequent attacks, tophi, joint damage, or kidney stones, with allopurinol as the preferred first-line ULT, starting at a low dose (≤100 mg/day) and gradually increasing to achieve a serum uric acid level below 6 mg/dL 1.
• Lifestyle modifications are crucial, including weight loss if overweight, limiting alcohol intake (especially beer), avoiding high-purine foods like organ meats and shellfish, and staying well-hydrated 1.
• Prophylactic low-dose colchicine (0.6mg daily) or NSAIDs may be prescribed when initiating ULT to prevent flares, with regular monitoring of serum uric acid levels essential to ensure treatment effectiveness 1.

Treatment Options

• For acute gout attacks, options include:
  • NSAIDs (e.g., naproxen 500mg twice daily or indomethacin 50mg three times daily) for 3-5 days
  • Colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve)
  • Oral prednisone (30-40mg daily for 3-5 days, then tapered) for patients who cannot take NSAIDs or colchicine

Long-term Management

• ULT should be continued indefinitely once started, as stopping can trigger flares 1.
• Regular monitoring of serum uric acid levels is essential to ensure treatment effectiveness 1. By following these recommendations, patients with gout can effectively manage their condition, reduce the risk of complications, and improve their quality of life.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The average is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout The minimal effective dosage is 100 to 200 mg daily and the maximal recommended dosage is 800 mg daily To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage. Gout flare prophylaxis with a non-steroidal anti-inflammatory drug (NSAID) or colchicine is recommended starting at least 1 week before initiation of KRYSTEXXA therapy and lasting at least 6 months, unless medically contraindicated or not tolerated.

The care plan for managing gout includes:

• Medication: allopurinol tablets with a dosage of 200 to 300 mg/day for mild gout and 400 to 600 mg/day for moderately severe tophaceous gout 2
• Dose adjustment: starting with a low dose of 100 mg daily and increasing at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained 2
• Gout flare prophylaxis: using a non-steroidal anti-inflammatory drug (NSAID) or colchicine, starting at least 1 week before initiation of therapy and lasting at least 6 months 3
• Monitoring: serum uric acid levels prior to infusions and considering discontinuing treatment if levels increase to above 6 mg/dL 3
• Lifestyle changes: increasing fluid intake to yield a daily urinary output of at least 2 liters and maintaining a neutral or slightly alkaline urine 2

From the Research

Care Plan for Gout

The care plan for managing gout involves a combination of pharmacological and non-pharmacological interventions.

• Acute Gout Management: Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout, with equal efficacy, and the choice is guided by comorbidities 4.
• Urate-Lowering Therapy: 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 4.
• Prophylaxis of Gout Flares: Colchicine is approved for the prophylaxis of gout flares in patients aged >16 years, and low-dose colchicine may have a cost and toxicity advantage over NSAIDs in the prophylaxis of gout when commencing therapy aimed at reducing elevated plasma urate concentrations 5, 6.
• New and Emerging Therapies: Febuxostat is another xanthine oxidase inhibitor, clinically equivalent to allopurinol, and new uricosuric drugs will soon become available, likely to have a role in the treatment of patients who do not respond to other drugs 4, 7.
• Personalization of Treatment: There is increasing personalization of treatment, adjusting pharmacotherapy depending on comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 7.

Pharmacotherapy Options

The following pharmacotherapy options are available for the management of gout:

• Colchicine: effective for the treatment of acute gout flares and prophylaxis of gout flares 5, 6
• NSAIDs: effective for the management of acute gout, but caution is required in view of their adverse effects, especially in the elderly 6
• Corticosteroids: useful for the management of acute gout, and oral steroids and corticotrophin (adrenocorticotrophic hormone) may have a small role in acute therapy 6
• Allopurinol: effective 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 4
• Febuxostat: another xanthine oxidase inhibitor, clinically equivalent to allopurinol 4, 7
• Uricosuric agents: increase uric acid excretion, and new drugs in this class will soon become available 4, 7
• IL-1 inhibitors: newly established as an option for flare refractory to standard therapies 7