What is the treatment for suspected gout?

Treatment of Suspected Gout

For suspected gout attacks, first-line treatment options include colchicine (within 12 hours of onset), NSAIDs, or oral corticosteroids, with the choice based on comorbidities, contraindications, and timing of treatment initiation. 1

Acute Gout Attack Management

First-Line Treatment Options

1. Colchicine:

   • Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
   • Timing: Most effective when started within 12-24 hours of symptom onset 1
   • Contraindications: Severe renal impairment, concomitant use of strong P-glycoprotein/CYP3A4 inhibitors 1
   • Common side effects: Gastrointestinal issues (diarrhea, nausea, vomiting) 1

2. NSAIDs:

   • Dosing: Full anti-inflammatory doses (e.g., naproxen, indomethacin, ibuprofen) 1
   • Consider: Add proton pump inhibitor if GI risk factors present 1
   • Contraindications: Renal disease, heart failure, cirrhosis 1

3. Corticosteroids:

   • Oral: Prednisone 30-35 mg daily for 3-5 days 1
   • Intra-articular: Joint aspiration and injection for monoarticular gout 1
   • Consider as first-line: In patients with contraindications to NSAIDs and colchicine 1

Treatment Selection Algorithm

• For mild/moderate pain (≤6/10) with 1-3 small joints or 1-2 large joints:

  • Choose monotherapy based on:
    • Time since onset: If <12 hours, colchicine is particularly effective
    • Renal function: Avoid colchicine and NSAIDs in severe renal impairment
    • Comorbidities: Consider corticosteroids if contraindications to other options

• For severe pain or polyarticular attack:

  • Consider combination therapy (e.g., colchicine plus NSAID) 1

• For patients with contraindications to all first-line options:

  • Consider IL-1 blockers 1

Important Clinical Considerations

Early Treatment

Treat as early as possible after symptom onset for best outcomes. Patient education should include instructions for self-medication at first warning symptoms 1.

Common Pitfalls to Avoid

1. Dosing errors with colchicine: High-dose colchicine regimens cause more adverse effects without additional benefit 1
2. Stopping urate-lowering therapy during an attack: Continue established urate-lowering therapy without interruption 1
3. Inadequate treatment duration: Continue treatment until complete resolution of the attack 1
4. Overlooking renal function: Adjust medication doses in patients with renal impairment 1

Long-Term Management Considerations

After treating the acute attack, consider:

1. Lifestyle modifications:

   • Weight loss if overweight
   • Limit alcohol (especially beer) and sugar-sweetened beverages
   • Reduce intake of purine-rich foods (organ meats, shellfish)
   • Encourage low-fat dairy products 1, 3

2. Urate-lowering therapy (ULT):

   • Consider for patients with recurrent attacks, tophi, urate arthropathy, or renal stones 1
   • Options include allopurinol (first-line) or febuxostat 1, 3
   • Target serum uric acid <6 mg/dL 1
   • When initiating ULT, provide prophylaxis with low-dose colchicine (0.5-1 mg/day) or low-dose NSAIDs for at least 6 months to prevent flares 1, 4

3. Medication review:

   • Consider substituting loop or thiazide diuretics if possible 1
   • For hypertension, consider losartan which increases uric acid excretion 3

By promptly treating suspected gout with appropriate anti-inflammatory therapy and addressing underlying hyperuricemia when indicated, most patients can achieve good symptom control and prevent recurrent attacks.