What is the recommended approach for a gout workup and management?

Comprehensive Approach to Gout Workup and Management

The recommended approach for gout workup and management includes patient education, lifestyle modifications, appropriate treatment of acute flares, and urate-lowering therapy (ULT) with a treat-to-target approach to achieve serum uric acid levels below 6 mg/dL. 1

Diagnosis and Initial Assessment

• Definitive diagnosis: Joint aspiration with demonstration of monosodium urate crystals under polarized light microscopy is the gold standard 1

• Clinical diagnosis: Based on typical presentation (acute monoarticular arthritis, often affecting the first metatarsophalangeal joint)

• Laboratory tests:

  • Serum uric acid level (may be normal during acute flares)
  • Complete blood count
  • Renal function tests
  • Liver function tests

• Imaging: Not required for diagnosis but may be helpful

  • Ultrasound can detect tophi and the "double contour" sign
  • Dual-energy CT can identify urate deposits

Patient Education (Critical Component)

Every person with gout should be fully informed about:

• Disease pathophysiology
• Available effective treatments
• Associated comorbidities
• Principles of managing acute attacks
• Importance of lifelong urate-lowering therapy 1

Management of Acute Gout Flares

Treat acute flares as early as possible with one of the following first-line options 1:

1. Colchicine:

   • Within 12 hours of flare onset
   • Loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1
   • Avoid in severe renal impairment
   • Do not use with strong P-glycoprotein/CYP3A4 inhibitors 1, 2

2. NSAIDs:

   • With proton pump inhibitor if appropriate
   • Avoid in severe renal impairment 1

3. Corticosteroids:

   • Oral: 30-35 mg/day of prednisolone equivalent for 3-5 days
   • Intra-articular injection for monoarticular gout 1

4. For patients with contraindications to the above:

   • IL-1 blockers may be considered 1

Urate-Lowering Therapy (ULT)

When to Initiate ULT:

ULT should be considered and discussed with every patient from the first presentation, and is indicated in patients with 1:

• Recurrent flares (≥2 attacks/year)
• Tophi
• Urate arthropathy
• Renal stones
• Young age (<40 years)
• Very high serum uric acid (>8.0 mg/dL)
• Comorbidities (renal impairment, hypertension, heart disease)

ULT Strategy:

1. Target serum urate level:

   • <6 mg/dL for all patients
   • <5 mg/dL for severe gout (tophi, chronic arthropathy, frequent attacks) 1

2. First-line ULT 1:

   • Allopurinol:

     • Start at low dose (100 mg/day, 50 mg if CKD stage 4+)
     • Increase by 100 mg every 2-4 weeks
     • Titrate to reach target serum urate
     • Maximum dose: up to 800 mg daily (adjust for renal function) 3
     • Consider HLA-B*5801 screening in high-risk populations (Korean, Han Chinese, Thai) 1

   • Febuxostat (alternative first-line):

     • If allopurinol not tolerated or contraindicated
     • No dose adjustment needed in mild-moderate renal impairment

3. Second-line options 1:

   • Switch to alternative XOI if target not reached
   • Add uricosuric agent (probenecid, benzbromarone)
   • Combination therapy (XOI + uricosuric)

4. For refractory cases:

   • Pegloticase for severe tophaceous gout unresponsive to other therapies 1

Flare Prophylaxis During ULT Initiation

• Prophylaxis is recommended during the first 6 months of ULT 1
• Options:
  • Colchicine 0.5-1 mg/day (reduce dose in renal impairment)
  • Low-dose NSAIDs if colchicine contraindicated 1

Lifestyle and Diet Recommendations

Every person with gout should receive advice regarding 1:

• Weight loss if appropriate
• Avoidance of:
  • Alcohol (especially beer and spirits)
  • Sugar-sweetened drinks
  • Heavy meals
  • Excessive intake of meat and seafood
• Encouragement of:
  • Low-fat dairy products
  • Regular exercise

Comorbidity Management

• Screen for and address associated conditions 1:

  • Renal impairment
  • Cardiovascular disease
  • Hypertension
  • Diabetes
  • Hyperlipidemia
  • Obesity

• Consider medication adjustments:

  • Substitute diuretics if possible
  • Consider losartan for hypertension (has uricosuric effect)
  • Consider statins or fenofibrate for hyperlipidemia 1

Monitoring

• Regular serum urate monitoring until target achieved
• Once at target, check every 6 months
• ULT should be maintained lifelong to prevent crystal reformation 1
• Monitor for medication side effects (liver function, renal function)

Common Pitfalls to Avoid

1. Failure to educate patients about the chronic nature of gout and importance of ULT
2. Inadequate ULT dosing - not titrating to reach target serum urate
3. Stopping ULT during acute flares - should be continued
4. Not providing prophylaxis when initiating ULT
5. Focusing only on acute flare management without addressing underlying hyperuricemia
6. Neglecting comorbidities that contribute to hyperuricemia

By following this comprehensive approach to gout management, focusing on patient education, proper acute flare treatment, and appropriate urate-lowering therapy with a treat-to-target strategy, most patients can achieve excellent disease control and prevention of long-term complications.