What is the recommended management for gout?

From the Guidelines

The recommended management for gout involves both acute treatment and long-term prevention strategies, with a focus on urate-lowering therapy and lifestyle modifications to reduce serum uric acid levels and prevent flares. For acute gout attacks, the most recent and highest quality study 1 recommends using colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids as first-line treatments. Colchicine is effective when started early, with a loading dose of 1 mg followed by 0.5 mg on day 1, while NSAIDs like naproxen or indomethacin can be used at standard doses. For patients who cannot take NSAIDs or colchicine, oral corticosteroids like prednisone are appropriate.

Acute Treatment

• Colchicine: 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve
• NSAIDs: naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 7-10 days or until symptoms resolve
• Oral corticosteroids: prednisone (30-40mg daily, tapered over 7-10 days) for patients who cannot take NSAIDs or colchicine

Long-term Prevention

• Urate-lowering therapy: allopurinol is typically started at 100mg daily and gradually increased to achieve a serum uric acid level below 6mg/dL, while febuxostat (40-80mg daily) is an alternative for those who cannot tolerate allopurinol
• Lifestyle modifications: weight loss if overweight, limiting alcohol (especially beer), reducing intake of purine-rich foods (red meat, seafood), and staying well-hydrated
• Prophylaxis: low-dose colchicine (0.6mg daily) or NSAIDs during the first 3-6 months of urate-lowering therapy to prevent flares as uric acid levels decrease

The 2020 American College of Rheumatology guideline for the management of gout 1 provides strong recommendations for the initiation of urate-lowering therapy in patients with tophaceous gout, radiographic damage, or frequent gout flares, and for the use of allopurinol as the preferred first-line urate-lowering therapy. The guideline also recommends a treat-to-target management strategy with urate-lowering therapy dose titration guided by serial serum urate measurements, with an target of <6 mg/dL.

From the FDA Drug Label

The dosage of allopurinol 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 To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol (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. The recommended management for gout includes:

• Medication: Allopurinol, with a dosage that varies based on the severity of the disease, ranging from 200 to 300 mg/day for mild gout to 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
• Monitoring: Regular monitoring of serum uric acid levels to adjust the dosage as needed
• Lifestyle changes: Maintaining a fluid intake sufficient to yield a daily urinary output of at least two liters and keeping a neutral or slightly alkaline urine 2
• Colchicine: For the treatment of gout flares, with a recommended dose of 0.6 mg (1 tablet) x 1 dose, followed by 0.3 mg (1/2 tablet) 1 hour later, with a dose to be repeated no earlier than 3 days 3

From the Research

Recommended Management for Gout

The recommended management for gout involves a combination of lifestyle modifications, pharmacological treatments, and preventive measures.

• Lifestyle Modifications: Patients with gout should limit their consumption of certain purine-rich foods (e.g., organ meats, shellfish) and avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 4. Consumption of vegetables and low-fat or nonfat dairy products should be encouraged.
• Acute Gout Treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout 4, 5, 6, 7, 8. These treatments are equally efficacious, and the choice of treatment should be guided by comorbidities.
• Urate-Lowering Therapy: Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 4, 5, 6, 7. Uricosuric agents, such as probenecid, can be used as adjuncts or in patients who cannot tolerate first-line agents 4, 5, 6.
• Preventive Measures: Patients receiving urate-lowering medications should be treated concurrently with NSAIDs, colchicine, or low-dose corticosteroids to prevent flares 4. Treatment should continue for at least three months after uric acid levels fall below the target goal in those without tophi, and for six months in those with a history of tophi 4.
• Emerging Therapies: New drugs, such as novel uricosurics (e.g., verinurad and arhalofenate) and IL-1β antagonists, are being developed and may have a role in the treatment of patients who do not respond to other drugs 6, 7.