From the Guidelines
The management of gout in soft tissues should prioritize a comprehensive approach targeting both acute inflammation and long-term prevention, with a focus on lowering uric acid levels and lifestyle modifications, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The goal of treatment is to reduce the frequency and severity of gout attacks, prevent tissue damage, and improve quality of life.
- For acute gout attacks, NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) are first-line treatments, typically continued for 7-10 days until symptoms resolve.
- 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).
- For patients with contraindications to these medications, corticosteroids can be used, either orally (prednisone 30-40mg daily, tapered over 7-10 days) or as an injection into affected areas.
- Ice application and rest of the affected area provide symptomatic relief. Long-term management focuses on lowering uric acid levels with medications like allopurinol (starting at 100mg daily, gradually increasing to achieve serum urate <6mg/dL) or febuxostat (40-80mg daily) 1. Lifestyle modifications are crucial, including:
- Weight loss if overweight
- Limiting alcohol (especially beer)
- Avoiding high-purine foods (organ meats, shellfish, red meat)
- Maintaining adequate hydration Urate-lowering therapy should be continued indefinitely to prevent recurrent attacks and tissue damage, as gout results from monosodium urate crystal deposition in joints and soft tissues due to persistent hyperuricemia 1.
From the FDA Drug Label
The etiology of this hyperuricemia is the overproduction of uric acid in relation to the patient's ability to excrete it If progressive deposition of urates is to be arrested or reversed, it is necessary to reduce the serum uric acid level below the saturation point to suppress urate precipitation. The action of allopurinol tablets differs from that of uricosuric agents, which lower the serum uric acid level by increasing urinary excretion of uric acid. Allopurinol tablets reduce both the serum and urinary uric acid levels by inhibiting the formation of uric acid
The management of gout in soft tissues involves reducing serum uric acid levels to prevent further deposition of urates. This can be achieved with allopurinol tablets, which inhibit the formation of uric acid. The dosage of allopurinol tablets varies with the severity of the disease, but the average dose is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout 2.
- Key considerations in managing gout in soft tissues include:
- Reducing serum uric acid levels to below the saturation point
- Inhibiting the formation of uric acid with allopurinol tablets
- Adjusting the dosage based on the severity of the disease and renal function
- Maintaining a neutral or slightly alkaline urine and adequate fluid intake to prevent renal precipitation of urates 2.
From the Research
Management of Gout in Soft Tissues
- Gout is characterized by the deposition of monosodium urate crystals in the joints and soft tissue 3
- The main clinical features of gout are hyperuricaemia, acute monoarticular arthritis, tophi and chronic arthritis, along with nephrolithiasis 3
- Treatment of acute gout includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids 4, 5, 6, 3, 7
- Drug treatment of hyperuricaemia includes allopurinol, sulfinpyrazone, probenecid and benzbromarone and should be used in patients with frequent gout attacks, tophi or urate nephropathy 3
- Allopurinol is an effective treatment for reducing concentrations of uric acid, and renal function guides the starting dose of allopurinol and the baseline serum uric acid concentration guides the maintenance dose 4
- Febuxostat is another xanthine oxidase inhibitor, clinically equivalent to allopurinol 4
- Uricosuric drugs, such as probenecid, increase uric acid excretion 4, 3, 7
Prevention of Gout Flares
- To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods and avoid alcoholic drinks and beverages sweetened with high-fructose corn syrup 5
- Consumption of vegetables and low-fat or nonfat dairy products should be encouraged 5
- The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid 5
- Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares 5, 6