From the Guidelines
The treatment of gouty arthritis and rheumatoid arthritis differs significantly, with gouty arthritis focusing on managing acute flares and preventing future attacks by targeting uric acid levels, whereas rheumatoid arthritis aims to control inflammation, prevent joint damage, and maintain function through a treat-to-target approach. The most recent and highest quality study, 1, provides guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. For acute gout flares, the following treatments are recommended:
- NSAIDs like indomethacin (50mg three times daily for 3-5 days) or naproxen (500mg twice daily for 3-5 days) as first-line treatments
- Colchicine (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve) is effective when started early
- Corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) are used when NSAIDs or colchicine are contraindicated For long-term management, urate-lowering therapy such as allopurinol (starting at 100mg daily, gradually increasing to 300-600mg daily) or febuxostat (40-80mg daily) is prescribed to maintain uric acid levels below 6mg/dL. In contrast, rheumatoid arthritis treatment typically includes methotrexate (starting at 7.5-10mg weekly, increasing to 15-25mg weekly as needed) combined with short-term low-dose prednisone (5-10mg daily), with additional disease-modifying antirheumatic drugs (DMARDs) or biologic agents added if response is inadequate after 3 months, as recommended by 1. Key differences in treatment approach between gouty arthritis and rheumatoid arthritis include:
- Targeting uric acid levels in gouty arthritis versus controlling inflammation and preventing joint damage in rheumatoid arthritis
- Use of urate-lowering therapy in gouty arthritis versus immunomodulatory therapy in rheumatoid arthritis
- Treatment goals, with gouty arthritis aiming to prevent future attacks and rheumatoid arthritis aiming to achieve clinical remission or low disease activity. Regular monitoring of disease activity and medication side effects is essential for both conditions, but rheumatoid arthritis typically requires more aggressive, long-term immunomodulatory therapy compared to the targeted anti-inflammatory and uric acid-lowering approach used for gout.
From the Research
Treatment Differences
The treatment of gouty arthritis and rheumatoid arthritis differs in several aspects:
- Gouty arthritis treatment focuses on managing acute attacks, lowering excess uric acid stores, and providing prophylaxis to prevent acute flares 2
- Rheumatoid arthritis treatment typically involves disease-modifying antirheumatic drugs (DMARDs), biologics, and corticosteroids to reduce inflammation and slow disease progression
- In gouty arthritis, nonpharmacological treatments such as topical ice and rest of the inflamed joint are useful during acute attacks, while NSAIDs are the preferred treatment 2
- Urate-lowering therapy is crucial in chronic gouty arthritis, with xanthine oxidase inhibitors like allopurinol and febuxostat being first-line treatments 3
Diagnostic Considerations
Diagnosing gouty arthritis and rheumatoid arthritis can be challenging, as they may present with similar symptoms:
- Chronic tophaceous gouty arthritis can mimic rheumatoid arthritis, and vice versa 4
- Accurate diagnosis relies on a combination of clinical features, laboratory findings, and radiological results, including the identification of monosodium urate (MSU) crystals in synovial and subcutaneous tissues 4
Treatment Options
Various treatment options are available for gouty arthritis:
- Colchicine, NSAIDs, and glucocorticosteroids can be used to relieve acute gouty arthritis attacks 3
- Uricosuric drugs like probenecid and benzbromarone can be used in combination with xanthine oxidase inhibitors for chronic gouty arthritis 3
- Alternative treatments like modified Simiao Tang have shown promise in reducing uric acid levels and improving symptoms 5
- Canakinumab can be considered for patients with difficult-to-treat gouty arthritis who are unable to use NSAIDs and colchicine 6