What is the treatment for gout?

Treatment of Gout

For acute gout attacks, corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option compared to NSAIDs and colchicine. 1

Acute Gout Management

First-line Options for Acute Gout Attacks

• Corticosteroids: Prednisolone 30-35 mg daily for 3-5 days 1

  • Advantages: Fewer adverse effects than NSAIDs, cost-effective
  • Contraindications: Systemic fungal infections
  • Potential adverse effects: Dysphoria, mood disorders, elevated blood glucose, immune suppression

• NSAIDs: Full anti-inflammatory/analgesic doses 1

  • Options: Naproxen, indomethacin, ibuprofen
  • Contraindications: Renal disease, heart failure, cirrhosis
  • Adverse effects: Gastrointestinal issues, potential ulcers and bleeding

• Colchicine: Low-dose regimen (1.2 mg followed by 0.6 mg 1 hour later) 1, 2

  • As effective as higher doses with fewer GI side effects
  • Contraindications: Severe renal/hepatic impairment, use with P-glycoprotein or CYP3A4 inhibitors
  • Dose adjustments needed for renal impairment

Treatment Timing and Approach

• Begin treatment as early as possible, ideally within 24 hours of symptom onset 1
• For mild/moderate attacks (1-3 small joints or 1-2 large joints), monotherapy is appropriate 1
• For severe or polyarticular attacks, combination therapy may be needed 1

Long-term Management

Urate-Lowering Therapy (ULT)

• When to initiate ULT:

  • After recurrent gout attacks (≥2 episodes per year) 1
  • In patients with tophi, chronic arthropathy, renal stones 1
  • Consider early in patients <40 years or with very high serum urate (>8.0 mg/dL) 1
  • Not recommended after first gout attack or in patients with infrequent attacks 1

• ULT Options:

  1. Allopurinol: First-line for patients with normal kidney function 1

     • Start at low dose (100 mg/day) and increase by 100 mg every 2-4 weeks until target reached 1
     • Adjust maximum dose based on creatinine clearance in renal impairment 1

  2. Febuxostat: Alternative when allopurinol is not tolerated or ineffective 1, 3

     • Effective at lowering serum uric acid to <6 mg/dL 3

  3. Uricosuric drugs (probenecid): For patients who cannot tolerate xanthine oxidase inhibitors 1

Target Serum Urate Level

• Maintain serum uric acid <6 mg/dL (360 μmol/L) 1
• For severe gout with tophi, target <5 mg/dL (300 μmol/L) until resolution 1

Prophylaxis During ULT Initiation

• Provide prophylaxis for first 6 months of ULT to prevent flares 1
• Options:
  • Colchicine 0.5-1 mg/day (adjust for renal impairment) 1
  • Low-dose NSAIDs if colchicine not tolerated 1

Lifestyle Modifications

• Weight loss if appropriate 1
• Avoid alcohol, especially beer and spirits 1, 4
• Avoid sugar-sweetened drinks and foods rich in fructose 1
• Limit intake of purine-rich foods (organ meats, shellfish) 4
• Encourage low-fat dairy products 1, 4
• Regular physical activity 1

Common Pitfalls to Avoid

1. Not adjusting colchicine dose in patients with renal impairment or those taking P-glycoprotein/CYP3A4 inhibitors 2

2. Discontinuing ULT during acute attacks - continue established ULT during flares 1

3. Inadequate ULT dosing - many patients require dose titration above standard doses to reach target uric acid levels 1

4. Failure to provide prophylaxis when initiating ULT, which can lead to increased flares 1

5. Not addressing comorbidities that contribute to hyperuricemia (hypertension, metabolic syndrome) 1, 5

6. Using high-dose colchicine regimens for acute attacks, which cause unnecessary gastrointestinal side effects 1

By following these evidence-based recommendations, clinicians can effectively manage both acute gout attacks and provide long-term care to prevent recurrent flares and complications.