What are the guidelines for managing Gout (Gouty Arthritis)?

From the Guidelines

Gout management should prioritize urate-lowering therapy (ULT) and lifestyle modifications to reduce serum uric acid levels and prevent flares, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Acute Treatment

For acute gout attacks, treatment should be started within 24 hours using NSAIDs (naproxen 500mg twice daily or indomethacin 50mg three times daily), colchicine (1.2mg initially, then 0.6mg one hour later, followed by 0.6mg once or twice daily), or corticosteroids (prednisone 30-40mg daily, tapered over 7-10 days) 1. The choice of drug should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved.

Long-term Management

Lifestyle modifications are crucial in managing gout and include:

• Limiting alcohol, purine-rich foods, and sugary beverages
• Maintaining hydration
• Encouraging low-fat dairy products and regular exercise
• Avoiding heavy meals and excessive intake of meat and seafood Urate-lowering therapy is indicated for patients with:
• Frequent attacks (≥2 per year)
• Tophi
• Joint damage
• Kidney stones Allopurinol is the first-line treatment, starting at 100mg daily, with increases by 100mg every 2-4 weeks to reach a target serum urate <6mg/dL, with a typical maintenance dose of 300-600mg daily 1. Febuxostat (40-80mg daily) is an alternative for those who cannot tolerate allopurinol.

Prophylaxis

Prophylaxis with colchicine (0.6mg daily) or low-dose NSAIDs should be used when initiating urate-lowering therapy for 3-6 months to prevent flares 1. Urate-lowering therapy should be continued indefinitely once started, with regular monitoring of serum uric acid levels to maintain a target level <6mg/dL.

Key considerations in gout management include:

• Patient education on self-medication at the first warning symptoms of a flare
• Avoiding colchicine in patients with severe renal impairment or those receiving strong P-glycoprotein and/or CYP3A4 inhibitors
• Adjusting allopurinol dosage in patients with renal impairment
• Considering pegloticase for patients with severe debilitating chronic tophaceous gout and poor quality of life who cannot achieve the uricaemia target with other available drugs.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The average is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout The minimal effective dosage is 100 to 200 mg daily and the maximal recommended dosage is 800 mg daily To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage.

The guidelines for managing Gout (Gouty Arthritis) include:

• Starting with a low dose of allopurinol (100 mg daily) and increasing at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained
• The average dosage is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout
• Maintaining a neutral or slightly alkaline urine and a daily urinary output of at least 2 liters
• Using colchicine or anti-inflammatory agents to suppress gouty attacks in some cases
• Monitoring patients with renal impairment closely and adjusting the dosage as needed 2
• For patients with severe renal impairment, the dose of allopurinol should not exceed 100 mg daily and for those with extreme renal impairment, the interval between doses may also need to be lengthened 2
• For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet) of colchicine 3

From the Research

Guidelines for Managing Gout (Gouty Arthritis)

The management of gout involves treating acute flares, lowering excess stores of uric acid to prevent flares, and providing prophylaxis to prevent acute flares 4. The following are some guidelines for managing gout:

• Acute Gout Treatment: Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout 5, 6, 4, 7, 8.
• Urate-Lowering Therapy: Xanthine oxidase inhibitors, such as allopurinol and febuxostat, are used to lower serum uric acid levels and prevent gout flares 5, 6, 4, 8.
• Uricosuric Agents: Probenecid, benzbromarone, and other uricosuric agents can be used to increase uric acid excretion and lower serum uric acid levels 5, 6, 4.
• Target Serum Uric Acid Level: The target serum uric acid level is <360 µmol/l (<6 mg/dl) 8.
• Treatment Adjustment: Therapy should be adjusted as necessary to achieve the therapeutic objective, with periodic review of uric acid levels and adjustment of treatment 8.
• Personalization of Treatment: Treatment should be personalized based on comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 5.
• Non-Pharmacologic Interventions: Non-pharmacologic interventions, such as lifestyle modifications and dietary changes, should be used in conjunction with pharmacologic therapy to manage gout 8.

Treatment Options

Some treatment options for gout include:

• NSAIDs: NSAIDs, such as ibuprofen and naproxen, can be used to treat acute gout flares 7.
• Colchicine: Colchicine can be used to treat acute gout flares and as a prophylactic agent to prevent flares 5, 4, 7.
• Corticosteroids: Corticosteroids, such as prednisone, can be used to treat acute gout flares 5, 6, 4, 7.
• Xanthine Oxidase Inhibitors: Xanthine oxidase inhibitors, such as allopurinol and febuxostat, can be used to lower serum uric acid levels and prevent gout flares 5, 6, 4, 8.
• Uricosuric Agents: Uricosuric agents, such as probenecid and benzbromarone, can be used to increase uric acid excretion and lower serum uric acid levels 5, 6, 4.