What is the treatment for gout?

Treatment of Gout

For acute gout attacks, first-line treatment options include NSAIDs, colchicine, or corticosteroids, with treatment initiated within 24 hours of symptom onset for optimal outcomes. 1

Acute Gout Attack Management

First-Line Treatment Options

1. NSAIDs

   • Full FDA-approved dose until attack resolves
   • Options include naproxen, indomethacin, and sulindac (FDA-approved for gout)
   • Contraindications: renal disease, heart failure, cirrhosis
   • Monitor for GI adverse effects (dyspepsia, ulcers, bleeding)

2. Colchicine

   • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later 1
   • Must be started within 36 hours of symptom onset for best efficacy
   • Contraindications: severe renal impairment, concomitant use of strong P-glycoprotein/CYP3A4 inhibitors
   • Dose adjustments needed for renal/hepatic impairment 2
   • Common adverse effects: diarrhea, nausea, vomiting

3. Corticosteroids

   • Oral: Prednisone 0.5 mg/kg/day for 5-10 days
   • Intra-articular: Variable dose based on joint size
   • Intramuscular: Triamcinolone acetonide 60 mg
   • Often preferred in patients with contraindications to NSAIDs/colchicine 1

Treatment Selection Considerations

• Patient comorbidities
• Previous response to treatment
• Time since symptom onset
• Number and type of joints involved
• Medication cost (corticosteroids generally lowest cost)

For Severe or Polyarticular Attacks

• Combination therapy may be appropriate:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality 1

Long-Term Management

Urate-Lowering Therapy (ULT)

• Indicated for patients with:
  • Recurrent gout attacks
  • Tophi
  • Chronic gouty arthropathy
  • Joint damage

Prophylaxis During ULT Initiation

• Essential to prevent flares when starting ULT
• Options:
  1. Low-dose colchicine: 0.6 mg once or twice daily (first-line)
  2. Low-dose NSAIDs: e.g., naproxen 250 mg twice daily with PPI if indicated
  3. Low-dose prednisone: <10 mg/day (if colchicine and NSAIDs contraindicated)

Duration of Prophylaxis

• Continue for at least 6 months, or
• 3 months after achieving target serum urate if no tophi present
• 6 months after achieving target serum urate if tophi present 1

Lifestyle Modifications

• Weight loss if overweight
• Avoid alcohol (especially beer and spirits)
• Avoid sugar-sweetened drinks
• Limit intake of meat and seafood
• Encourage low-fat dairy products
• Regular exercise 1

Common Pitfalls to Avoid

1. Delaying treatment - Initiate therapy within 24 hours of symptom onset
2. Interrupting ULT during acute attacks - Continue ULT even during flares 1
3. Using high-dose colchicine - The older high-dose regimen causes significant GI toxicity
4. Inadequate prophylaxis duration - Premature discontinuation increases flare risk
5. Overlooking comorbidities - Screen for and manage cardiovascular risk factors, renal impairment, and other conditions 1
6. Ignoring drug interactions - Particularly important with colchicine, which has potentially serious interactions with P-glycoprotein and CYP3A4 inhibitors 2

For patients with renal impairment, colchicine dosing must be adjusted, and in severe impairment, treatment courses should not be repeated more than once every two weeks 2. Similar caution applies to patients with hepatic impairment.