What are the treatment options for acute and chronic gout?

From the Guidelines

Treatment for acute gout should focus on reducing inflammation and pain quickly, with first-line options including corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine, as recommended by the American College of Physicians 1. The goal of treatment is to reduce morbidity, mortality, and improve quality of life for patients with gout.

Acute Gout Treatment

For acute gout, the following options are recommended:

• Corticosteroids, such as oral prednisone (30-40mg daily for 3-5 days, then tapered)
• NSAIDs, such as indomethacin (50mg three times daily) or naproxen (500mg twice daily)
• Colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily)

Chronic Gout Management

For chronic gout management, urate-lowering therapy is essential, typically with:

• Allopurinol (starting at 100mg daily, gradually increasing to 300-600mg daily)
• Febuxostat (40-80mg daily) These medications inhibit xanthine oxidase, reducing uric acid production. Probenecid (250mg twice daily, increasing to 500mg twice daily) can increase uric acid excretion when other options aren't suitable. Treatment should continue indefinitely to maintain uric acid levels below 6mg/dL. Lifestyle modifications are also important, including weight loss, limiting alcohol (especially beer), reducing intake of purine-rich foods like red meat and seafood, and staying well-hydrated. Patients should understand that initial urate-lowering therapy may temporarily increase gout flares, so prophylactic colchicine (0.6mg daily) is often prescribed for the first 3-6 months of treatment, as supported by the American College of Rheumatology guidelines 1. Additionally, the EULAR evidence-based recommendations for gout also emphasize the importance of patient education, modification of adverse lifestyle, and treatment of associated comorbidity and risk factors 1.

Some key points to consider in gout management include:

• An acute gouty arthritis attack should be treated with pharmacologic therapy, initiated within 24 hours of onset
• Established pharmacologic ULT should be continued, without interruption, during an acute attack of gout
• Pharmacologic anti-inflammatory prophylaxis is recommended for all gout patients when pharmacologic urate-lowering is initiated, and should be continued if there is any clinical evidence of continuing gout disease activity and/or the serum urate target has not yet been achieved
• Oral colchicine is appropriate first-line gout attack prophylaxis therapy, including with appropriate dose adjustment in chronic kidney disease and for drug interactions, unless there is lack of tolerance or medical contra-indication
• Low dose NSAID therapy is an appropriate choice for first-line gout attack prophylaxis, unless there is lack of tolerance or medical contra-indication, as stated in the 2012 American College of Rheumatology guidelines 1.

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. KRYSTEXXA® (pegloticase) is a PEGylated uric acid specific enzyme indicated for the treatment of chronic gout in adult patients refractory to conventional therapy Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis

The treatment options for acute and chronic gout include:

• Allopurinol (2): for full control of gout and to lower serum uric acid to normal or near-normal levels
• Pegloticase (3): for the treatment of chronic gout in adult patients refractory to conventional therapy
• Indomethacin (4): for relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis Key considerations:
• The dosage of these medications varies with the severity of the disease
• Patients should be closely monitored for anaphylaxis and infusion reactions when using pegloticase
• Indomethacin should be used with caution in patients with renal impairment or those taking other NSAIDs.

From the Research

Treatment Options for Acute Gout

• Non-steroidal anti-inflammatory agents, colchicine, or corticosteroid-based therapies are used to terminate the acute phase of gouty arthritis 5
• Colchicine, NSAIDs, and oral or intramuscular corticosteroids are standard pharmacotherapies for gout flares, with IL-1 inhibitors as an option for flare refractory to standard therapies 6
• Intra-articular glucocorticosteroid therapy is useful and very safe, while oral steroids and corticotrophin may have a small role in acute therapy 7

Treatment Options for Chronic Gout

• Urate-lowering therapies, such as allopurinol and febuxostat, aim to prevent gout flares and reduce serum uric acid levels 5, 6
• Uricosuric agents, such as probenecid, increase uric acid excretion and are used as adjuncts or second-line treatments 5, 8, 9
• Febuxostat is a therapeutic alternative to allopurinol, and new uricosuric drugs are being developed for patients who do not respond to other treatments 6, 8, 9

Lifestyle Modifications and Comorbidities

• Alcohol and dietary consumption are related to hyperuricemia and acute gout, and recent data sheds light on important dietary modifications that may help in the treatment of gout 5
• Comorbidities, such as chronic kidney disease and ischemic heart disease, should be considered when adjusting pharmacotherapy, and patient preference should also be taken into account 6
• Education of patients, identification, and correction of cardiovascular risk factors are important aspects of gout management 9