What is the treatment for gout (Gouty Arthritis)?

Treatment of Gout (Gouty Arthritis)

The treatment of gout requires a three-pronged approach: managing acute attacks with anti-inflammatory medications started within 24 hours of symptom onset, lowering uric acid levels long-term with urate-lowering therapy (ULT), and providing prophylaxis during ULT initiation to prevent flares. 1

Acute Gout Attack Management

First-Line Options (start within 24 hours of symptom onset):

1. NSAIDs at full anti-inflammatory doses

   • FDA-approved options: naproxen, indomethacin, sulindac 1
   • Continue at full dose until attack completely resolves 1
   • Caution in patients with renal impairment, GI issues, or cardiovascular disease 2

2. Oral Colchicine

   • Most effective if started within 36 hours of symptom onset 1
   • Dosing: 1.2 mg initially, followed by 0.6 mg one hour later 1
   • After 12 hours, may continue with prophylactic dosing (0.6 mg once or twice daily) until attack resolves 1
   • Adjust dose in renal impairment and with drug interactions 3

3. Corticosteroids

   • For 1-2 joints: Intra-articular injection (dose varies by joint size) 1
   • Oral prednisone: 0.5 mg/kg daily for 5-10 days, then stop; OR 2-5 days at full dose followed by 7-10 day taper 1
   • Alternative: Methylprednisolone dose pack 1

For Severe Attacks or Polyarticular Gout:

Combination therapy is appropriate using full doses of two modalities 1:

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

Important Principles:

• Do NOT interrupt ongoing urate-lowering therapy during an acute attack 1
• If inadequate response (defined as <20% improvement in pain within 24 hours or <50% improvement at 24 hours), add a second agent 1

Long-Term Management (Urate-Lowering Therapy)

Indications for ULT:

• Recurrent gout attacks
• Tophi
• Chronic gouty arthropathy
• Joint damage

First-Line ULT Options:

• Xanthine oxidase inhibitors (allopurinol, febuxostat) 4
• Uricosuric drugs (probenecid) for patients who cannot tolerate xanthine oxidase inhibitors 5, 4

Prophylaxis During ULT Initiation

When to Start:

With or just prior to initiating ULT 1

Medication Options:

1. First-line: Low-dose colchicine

   • 0.6 mg once or twice daily 1

2. Alternative: Low-dose NSAIDs

   • Example: Naproxen 250 mg twice daily with PPI if indicated 1

3. Second-line: Low-dose prednisone

   • <10 mg/day (if colchicine and NSAIDs not tolerated) 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

Lifestyle Modifications

• Limit purine-rich foods (organ meats, shellfish)
• Avoid alcoholic drinks (especially beer)
• Avoid beverages sweetened with high-fructose corn syrup
• Encourage consumption of vegetables and low-fat dairy products 4
• Maintain adequate hydration

Special Considerations

Renal Impairment:

• For severe renal impairment: Colchicine dose should be reduced to 0.3 mg/day for prophylaxis 3
• For dialysis patients: Colchicine 0.3 mg twice weekly 3
• For acute flares in dialysis patients: Single dose of 0.6 mg, not repeated more than once every two weeks 3

Hepatic Impairment:

• Monitor closely for adverse effects
• Consider dose reduction in severe hepatic impairment 3

Common Pitfalls to Avoid

1. Delaying treatment of acute attacks (should start within 24 hours)
2. Using high-dose colchicine regimens (increases toxicity risk)
3. Stopping ULT during acute attacks (should be continued)
4. Failing to provide prophylaxis when initiating ULT
5. Inadequate duration of prophylaxis
6. Not adjusting medication doses in patients with renal or hepatic impairment

Remember that gout is a chronic disease requiring long-term management. Adherence to urate-lowering medications is crucial for treatment success and prevention of joint damage 6.