What are the treatment options for gout?

From the Guidelines

Gout treatment should prioritize a combination of acute attack management and long-term prevention, with urate-lowering therapy (ULT) initiated as soon as possible, ideally with allopurinol as the first-line agent, and serum uric acid levels maintained below 6mg/dL, as recommended by the 2020 American College of Rheumatology guideline 1. The management of gout involves several key components, including:

• Acute attack treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or corticosteroids
• Long-term prevention through lifestyle modifications, such as limiting alcohol and purine-rich foods, and maintaining a healthy weight
• Urate-lowering therapy (ULT) with allopurinol or febuxostat to inhibit uric acid production, or probenecid to increase uric acid excretion Some key points to consider when managing gout include:
• Initiating ULT as soon as possible, ideally with allopurinol as the first-line agent, and titrating the dose to achieve a serum uric acid level below 6mg/dL 1
• Using prophylactic colchicine or low-dose NSAIDs when initiating ULT to prevent flares caused by changing uric acid levels 1
• Continuing ULT indefinitely to maintain serum uric acid levels below 6mg/dL and prevent future gout attacks 1
• Considering patient factors, such as chronic kidney disease, when selecting a ULT agent and determining the optimal dose 1 It's also important to note that the 2020 American College of Rheumatology guideline recommends against using pegloticase as first-line therapy due to cost, safety concerns, and favorable benefit-to-harm ratios of other untried treatment options 1. Overall, the goal of gout treatment is to reduce morbidity, mortality, and improve quality of life by managing acute attacks, preventing future attacks, and reducing the risk of long-term complications.

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). For these patients, the treatment course should not be repeated more than once every two weeks

The treatment options for gout include:

• Colchicine for the treatment of gout flares
• Dose adjustment may be necessary in patients with renal impairment or hepatic impairment
• Alternate therapy should be considered in patients with severe impairment or those requiring repeated courses of treatment
• Patients undergoing dialysis should receive a reduced dose of 0.6 mg (one tablet) and the treatment course should not be repeated more than once every two weeks 2 2 2

From the Research

Treatment Options for Gout

The treatment options for gout can be categorized into two main areas: acute gout management and urate-lowering therapy.

• Acute Gout Management: This involves the use of medications to reduce the pain and inflammation associated with a gout flare. Options include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5, 6
  • Colchicine 3, 4, 7, 5, 6
  • Corticosteroids 3, 4, 7, 5, 6
  • IL-1 inhibitors for flares refractory to standard therapies 5, 6

• Urate-Lowering Therapy: This involves the use of medications to reduce uric acid levels in the blood, which can help prevent future gout flares. Options include:

  • Allopurinol 3, 4, 7, 5, 6
  • Febuxostat 3, 4, 7, 5, 6
  • Uricosuric agents such as probenecid 3, 4, 7, 5, 6
  • Novel uricosurics like verinurad and arhalofenate 6
  • Pegloticase for patients with recalcitrant gout 6

Lifestyle Modifications

In addition to medication, lifestyle modifications can also play a role in managing gout. These include:

• Limiting consumption of purine-rich foods (e.g., organ meats, shellfish) 3
• Avoiding alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 3
• Encouraging consumption of vegetables and low-fat or nonfat dairy products 3
• Discontinuing diuretics if possible 7
• Using fenofibrate in the presence of dyslipidemia and losartan in patients with high blood pressure 7