What are the treatment options for acute and chronic gout?

Treatment Options for Acute and Chronic Gout

For optimal management of gout, clinicians should choose corticosteroids, NSAIDs, or colchicine for acute attacks, while reserving urate-lowering therapy for patients with recurrent attacks, tophi, or chronic gouty arthritis. 1

Acute Gout Treatment

First-Line Options (choose based on patient factors)

1. Corticosteroids

   • Recommended as first-line therapy due to safety profile and low cost 1
   • Dosing options:
     • Oral prednisone: 0.5 mg/kg per day for 5-10 days 1
     • Methylprednisolone dose pack 1
     • Intra-articular injection for single joint involvement 1
   • Contraindications: Systemic fungal infections 1
   • Adverse effects: Dysphoria, mood disorders, elevated blood glucose, immune suppression 1

2. NSAIDs

   • Use FDA-approved anti-inflammatory doses 1
     • FDA-approved for gout: naproxen, indomethacin, sulindac 1
     • Continue at full dose until attack resolves completely 1
   • Contraindications: Renal disease, heart failure, cirrhosis 1
   • Adverse effects: Dyspepsia, GI bleeding, ulcers, perforations 1

3. Colchicine

   • Use low-dose regimen: 1.2 mg followed by 0.6 mg one hour later 1
   • Only effective if started within 36 hours of symptom onset 1
   • After initial loading, continue with 0.6 mg once or twice daily until attack resolves 1
   • Contraindications: Severe renal/hepatic impairment, drug interactions with CYP3A4 inhibitors 1
   • Adverse effects: Diarrhea, nausea, vomiting, abdominal pain 1

Combination Therapy

For severe attacks or polyarticular gout (≥4 joints or ≥3 large joints), consider combination therapy 1:

• Colchicine + NSAIDs
• Oral corticosteroids + colchicine
• Intra-articular steroids with any other modality

Chronic Gout Management

When to Start Urate-Lowering Therapy (ULT)

ULT should be initiated in patients with:

• Recurrent gout attacks
• Tophi
• Chronic gouty arthropathy
• Joint damage on imaging 1

Note: ULT is not recommended after a first gout attack or in patients with infrequent attacks 1

Urate-Lowering Medication Options

1. Xanthine Oxidase Inhibitors (first-line)

   • Allopurinol:
     • Starting dose: 100 mg daily 2
     • Increase by 100 mg weekly until target serum uric acid <6 mg/dL 2
     • Typical maintenance: 200-300 mg/day for mild gout, 400-600 mg/day for severe tophaceous gout 2
     • Maximum dose: 800 mg daily 2
     • Dose adjustment required in renal impairment:
       • CrCl 10-20 mL/min: 200 mg/day
       • CrCl <10 mL/min: ≤100 mg/day 2

2. Advanced Options for Refractory Gout

   • Pegloticase: 8 mg IV every two weeks for patients who have failed conventional therapy 3
     • Monitor serum uric acid levels before each infusion
     • Consider discontinuation if levels rise above 6 mg/dL on two consecutive measurements 3
     • Requires premedication with antihistamines and corticosteroids due to risk of infusion reactions 3

Prophylaxis During ULT Initiation

To prevent flares when starting ULT, use prophylactic therapy 1:

1. Low-dose colchicine: 0.6 mg once or twice daily 1
2. Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI if indicated 1
3. Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1

Duration of prophylaxis:

• At least 6 months, OR
• 3 months after achieving target serum urate (if no tophi), OR
• 6 months after achieving target serum urate (if tophi present) 1

Important Clinical Pearls

1. Do not discontinue ULT during an acute attack - continue therapy while treating the acute flare 1

2. Initiate treatment for acute attacks within 24 hours of symptom onset for optimal outcomes 1

3. Target serum urate level should be below 6 mg/dL (or below 5 mg/dL in patients with tophi) 1, 2

4. Educate patients to initiate treatment at first signs of an acute attack without waiting to consult their healthcare provider 1

5. Monitor for drug interactions - particularly with colchicine and CYP3A4 inhibitors which can lead to serious toxicity 1

Non-Pharmacologic Management

• Limit consumption of purine-rich foods (organ meats, shellfish) 4
• Avoid alcoholic drinks, especially beer 4
• Avoid beverages sweetened with high-fructose corn syrup 4
• Encourage consumption of vegetables and low-fat dairy products 4
• Maintain adequate hydration with at least 2 liters of fluid daily 2
• Weight loss if overweight/obese 4