What are the next steps in workup or treatment for a patient with suspected gout?

Management of Suspected Gout: Diagnostic and Treatment Algorithm

For patients with suspected gout, prompt diagnosis followed by appropriate anti-inflammatory treatment should be initiated within 24 hours of symptom onset, with subsequent consideration of urate-lowering therapy based on specific clinical criteria. 1

Diagnostic Workup

Initial Assessment

• Joint aspiration with synovial fluid analysis for monosodium urate crystals (gold standard)
• Serum uric acid level (note: may be normal during acute flares)
• Assessment for comorbidities: renal function, cardiovascular risk factors, diabetes
• Imaging if diagnosis uncertain:
  • Ultrasound: "double contour" sign on cartilage surfaces
  • Dual-energy CT: can detect urate crystal deposits

Key Clinical Features

• Sudden onset of severe joint pain (often first metatarsophalangeal joint)
• Erythema, swelling, and tenderness
• Self-limited episodes lasting 7-14 days without treatment
• History of similar episodes with complete resolution between attacks

Acute Flare Management

First-Line Options (start within 24 hours of onset) 1

1. Oral Colchicine

   • Dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later
   • Most effective if started within 36 hours of symptom onset
   • Contraindications: severe renal impairment, concomitant strong P-glycoprotein/CYP3A4 inhibitors

2. NSAIDs (at full FDA-approved doses)

   • Options: naproxen, indomethacin, or sulindac (FDA-approved for gout)
   • Continue until flare completely resolves
   • Contraindications: renal impairment, history of GI bleeding, heart failure

3. Corticosteroids

   • Oral: Prednisone 0.5 mg/kg/day for 5-10 days or 2-5 days with 7-10 day taper
   • Intra-articular: For monoarticular gout (dose varies by joint size)
   • Intramuscular: Triamcinolone acetonide 60 mg (when oral dosing not possible)

Second-Line Options 1

• IL-1 Inhibitors: Consider when first-line options are ineffective, contraindicated, or poorly tolerated
• Topical Ice: Recommended as adjuvant therapy

Long-Term Management

Indications for Urate-Lowering Therapy (ULT) 1

• Strong recommendations for initiating ULT:

  • Frequent gout flares (≥2/year)
  • Presence of tophi
  • Radiographic damage attributable to gout

• Conditional recommendations for initiating ULT after first flare:

  • CKD stage ≥3
  • Serum urate >9 mg/dL
  • Urolithiasis

ULT Approach 1, 2, 3

1. First-line agent: Allopurinol

   • Starting dose: 100 mg daily
   • Increase by 100 mg weekly until target serum urate achieved
   • Target serum urate: <6 mg/dL (<5 mg/dL if tophi present)
   • Dose adjustment for renal impairment:
     • CrCl 10-20 mL/min: 200 mg/day maximum
     • CrCl <10 mL/min: 100 mg/day maximum

2. Alternative agents:

   • Febuxostat: Consider when allopurinol not tolerated or contraindicated
   • Probenecid: Option for patients with normal renal function and underexcretion of urate
   • Pegloticase: Reserved for severe refractory gout when other ULTs have failed

Anti-inflammatory Prophylaxis 1, 2

• Always initiate prophylaxis with ULT to prevent flares
• Options:
  • Low-dose colchicine: 0.6 mg once or twice daily (first-line)
  • Low-dose NSAIDs with PPI if indicated (e.g., naproxen 250 mg twice daily)
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs contraindicated
• Duration:
  • At least 3-6 months after starting ULT
  • At least 3 months after achieving target urate level (if no tophi)
  • At least 6 months after achieving target urate level (if tophi present)

Special Considerations

Timing of ULT Initiation 1

• ULT can be started during an acute flare (conditional recommendation)
• Benefits include patient motivation and time efficiency
• Must provide clear education about flare management versus long-term ULT

Treatment Monitoring

• Check serum urate 2-4 weeks after starting or adjusting ULT
• Adjust ULT dose to maintain target serum urate level
• Monitor renal function, especially in patients on allopurinol
• Assess for flare frequency and resolution of tophi

Common Pitfalls to Avoid

1. Discontinuing ULT during acute flares (should be continued)
2. Failing to provide anti-inflammatory prophylaxis when starting ULT
3. Using fixed-dose ULT without titration to target serum urate
4. Inadequate patient education about chronic nature of disease
5. Overlooking comorbidities that may affect treatment choices

By following this algorithm, clinicians can effectively diagnose and manage gout, reducing the risk of recurrent flares, preventing joint damage, and improving patients' quality of life.