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 or tophi, accompanied by appropriate prophylaxis to prevent flares during initiation of therapy. 1

Acute Gout Management

First-Line Treatment Options

Treatment should be initiated within 24 hours of symptom onset for best outcomes 1:

1. Corticosteroids:

   • First-line option due to safety profile and low cost 1
   • Oral prednisone 0.5 mg/kg/day for 5-10 days, or
   • Methylprednisolone dose pack
   • Intra-articular injection for single joint involvement
   • Contraindicated in systemic fungal infections 1

2. NSAIDs:

   • Full anti-inflammatory dosing 1
   • FDA-approved options:
     • Naproxen (Evidence A)
     • Indomethacin (Evidence A)
     • Sulindac (Evidence B)
   • No evidence that indomethacin is superior to other NSAIDs 1
   • Contraindicated in renal disease, heart failure, or cirrhosis 1

3. Colchicine:

   • Only effective if started within 36 hours of attack onset 1
   • Low-dose regimen: 1.2 mg followed by 0.6 mg one hour later 1
   • Then 0.6 mg once or twice daily until attack resolves 1
   • Contraindicated in renal/hepatic impairment and with CYP3A4 inhibitors 1

Treatment Selection Based on Attack Severity

• Mild/moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints: Monotherapy with any of the above options 1
• Severe pain or polyarticular attack: Combination therapy may be appropriate 1

Combination Therapy Options 1

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

Chronic Gout Management

When to Initiate Urate-Lowering Therapy (ULT)

• Not recommended after first gout attack or for infrequent attacks 1
• Recommended for patients with:
  • Recurrent attacks (≥2 per year)
  • Tophi
  • Chronic gouty arthropathy
  • Joint damage
  • Renal stones 1

Urate-Lowering Medications

1. Xanthine Oxidase Inhibitors (First-line):

   • Allopurinol:

     • Starting dose: 100 mg daily
     • Increase by 100 mg weekly
     • Target serum uric acid: <6 mg/dL
     • Maintenance dose: 200-300 mg/day for mild gout; 400-600 mg/day for moderately severe tophaceous gout 2
     • Maximum dose: 800 mg daily 2
     • Dose adjustment required for renal impairment 2

   • Febuxostat:

     • Alternative when allopurinol is not tolerated
     • Higher cost than allopurinol 1

2. Uricosuric Agents (Second-line):

   • Probenecid
   • Used when xanthine oxidase inhibitors are contraindicated or ineffective 3

3. Uricolytic Drugs:

   • Pegloticase:
     • For chronic gout refractory to conventional therapy
     • 8 mg IV infusion every two weeks
     • Monitor serum uric acid levels prior to infusions
     • Consider discontinuation if levels increase above 6 mg/dL 4
     • Risk of anaphylaxis and infusion reactions 4

Prophylaxis During ULT Initiation

Prophylaxis should be started with or just prior to ULT initiation 1:

1. First-line options:

   • Low-dose colchicine (0.6 mg once or twice daily)
   • Low-dose NSAIDs with proton pump inhibitor if indicated

2. Second-line option:

   • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are not tolerated

Duration of Prophylaxis 1

• 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)

Common Pitfalls and Caveats

1. Do not discontinue ULT during an acute attack - continue established therapy 1

2. Patient education is crucial - provide instructions so patients can initiate treatment upon first signs of an acute attack 1

3. Colchicine dosing errors - high-dose colchicine regimens are no longer recommended due to toxicity; use low-dose protocol 1

4. Inadequate prophylaxis duration - premature discontinuation of prophylaxis when starting ULT often leads to breakthrough flares 1

5. Insufficient ULT dosing - failure to titrate allopurinol to achieve target serum urate levels is a common cause of treatment failure 2

6. Monitoring - serum urate levels should be used to guide ULT dosing, with a target of <6 mg/dL 2

7. Drug interactions - be aware of potential interactions, particularly with colchicine and CYP3A4 inhibitors 1