What are the treatment options for acute and chronic gout?

Treatment Options for Acute and Chronic Gout

For acute gout attacks, first-line treatment options include corticosteroids, NSAIDs, or colchicine, with medication selection based on patient comorbidities and joint involvement. 1, 2

Acute Gout Management

First-Line Medications

1. NSAIDs

   • Use full FDA-approved anti-inflammatory doses until attack resolves 1, 2
   • Examples: naproxen, indomethacin, sulindac (FDA-approved for acute gout) 1
   • Contraindications: GI issues, history of ulcers, renal disease, heart failure, cirrhosis 2

2. Colchicine

   • Low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later 1, 2
   • Most effective when started within 36 hours of symptom onset 2
   • Contraindications: severe renal impairment, concurrent use of CYP3A4/P-glycoprotein inhibitors 2

3. Corticosteroids

   • Oral prednisone: 0.5 mg/kg per day for 5-10 days at full dose then stop, OR 2-5 days at full dose followed by 7-10 day taper 1, 2
   • Intra-articular: dose varies by joint size 1, 2
   • Intramuscular: triamcinolone acetonide 60 mg, followed by oral prednisone 1, 2
   • Preferred in patients with renal disease, heart failure, cirrhosis, or contraindications to NSAIDs/colchicine 2

Treatment Approach

• Initiate treatment within 24 hours of symptom onset for optimal results 1
• For severe or polyarticular attacks, consider combination therapy (colchicine + NSAIDs or colchicine + corticosteroids) 2
• Do not interrupt ongoing urate-lowering therapy during an acute attack 1

Chronic Gout Management

Urate-Lowering Therapy (ULT)

Indications for ULT:

• Recurrent gout attacks (≥2 per year)
• Presence of tophi
• Chronic gouty arthritis
• Joint damage
• Urolithiasis
• Chronic kidney disease 2, 3

First-line ULT:

• Allopurinol is the preferred first-line agent 2, 4
  • Starting dose: 100 mg daily
  • Increase by 100 mg weekly until target serum uric acid level is achieved
  • Target serum uric acid: <6 mg/dL (<5 mg/dL for severe gout)
  • Maximum dose: 800 mg daily
  • Dose adjustment required in renal impairment 4

Alternative ULT:

• Febuxostat (note: associated with increased cardiovascular mortality, not routinely recommended) 3
• Pegloticase for refractory gout (8 mg IV every two weeks) 5

Prophylaxis During ULT Initiation

• Start prophylaxis with colchicine (0.6 mg/day) or low-dose NSAIDs when initiating ULT 2
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi are present, or 6 months after achieving target serum urate if tophi are present 2

Special Considerations

Medication Selection Based on Comorbidities

• Renal disease: Prefer corticosteroids; avoid NSAIDs; adjust colchicine and allopurinol doses 2, 4
• Diabetes/uncontrolled hypertension: Consider NSAIDs or colchicine over corticosteroids 2
• GI issues/history of ulcers: Avoid NSAIDs; prefer corticosteroids or colchicine 2
• Heart failure/cirrhosis: Avoid NSAIDs; prefer corticosteroids 2

Monitoring

• Monitor serum uric acid levels regularly when on ULT
• For colchicine: monitor for neuromuscular toxicity, especially with renal impairment or statin co-therapy 2
• For corticosteroids: monitor for dysphoria, mood disorders, elevated blood glucose, and immune suppression 2
• For allopurinol: adjust dose based on renal function 4

Lifestyle Modifications

• Reduce excess body weight
• Regular exercise
• Smoking cessation
• Avoid excess alcohol (especially beer)
• Avoid sugar-sweetened drinks and high-fructose foods
• Limit purine-rich foods (organ meats, shellfish)
• Ensure adequate fluid intake (at least 2 liters daily) 2, 6

Common Pitfalls to Avoid

1. Failing to start treatment promptly - Initiate treatment within 24 hours of symptom onset
2. Interrupting ULT during acute attacks - Continue ULT during acute flares
3. Inadequate prophylaxis when starting ULT - Always use prophylactic therapy when initiating ULT
4. Using fixed-dose allopurinol - Titrate to achieve target serum uric acid levels
5. Overlooking comorbidities when selecting therapy - Consider patient-specific factors when choosing treatment

By following these evidence-based recommendations, clinicians can effectively manage both acute gout attacks and prevent recurrent episodes, ultimately improving patients' quality of life and reducing morbidity associated with gout.