What are the treatment options for acute and chronic gout?

Treatment Options for Acute and Chronic Gout

Acute Gout Treatment

For acute gout attacks, first-line treatment options include colchicine, NSAIDs, or corticosteroids, with the choice depending on patient comorbidities and contraindications. 1

First-line options:

1. Colchicine:

   • Low-dose regimen: 1-1.2 mg loading dose, followed by 0.5-0.6 mg on day 1, then 0.5-1 mg daily until attack resolves 1
   • More effective than placebo for achieving treatment success (50% or greater pain reduction) 2
   • Low-dose colchicine has similar efficacy to high-dose with fewer adverse events 2
   • Dose reduction required in moderate to severe chronic kidney disease 1
   • Avoid or reduce dose when used with CYP3A4 or P-glycoprotein inhibitors 1

2. NSAIDs:

   • Use at full anti-inflammatory doses until attack resolves 1
   • Options include indomethacin, ibuprofen, and naproxen
   • Contraindicated in patients with cardiovascular disease or heart failure due to increased cardiovascular risk 1
   • Can cause dose-dependent reduction in renal blood flow and risk of acute kidney injury 1

3. Corticosteroids:

   • Intra-articular injection: Highly effective and safe for acute gout affecting one or few joints 1
   • Particularly appropriate for patients with cardiovascular comorbidities 1
   • Oral prednisone: 0.5 mg/kg per day for 5-10 days 1
   • No dose adjustment needed for mild renal impairment 1
   • Triamcinolone acetonide 60 mg intramuscularly has been shown to be as effective as indomethacin 3

Key principles for acute treatment:

• Initiate treatment within 24 hours of symptom onset 1
• Do not interrupt urate-lowering therapy during acute attacks 1
• Consider patient comorbidities when selecting therapy 1

Chronic Gout Management (Urate-Lowering Therapy)

Indications for urate-lowering therapy:

• Recurrent gout attacks
• Presence of tophi
• Chronic gouty arthritis
• Joint damage
• Urolithiasis
• Chronic kidney disease 1

First-line urate-lowering therapy:

Allopurinol is the preferred first-line agent, especially for patients with cardiovascular disease. 1

• Starting dose: 100 mg daily
• Titration: Increase by 100 mg every 2-4 weeks
• Target serum uric acid: <6 mg/dL (<5 mg/dL for severe gout) 1, 4
• Dosage range: 200-300 mg/day for mild gout; 400-600 mg/day for moderately severe tophaceous gout 4
• Maximum recommended dosage: 800 mg daily 4
• Dose adjustment for renal impairment:
  • Creatinine clearance 10-20 mL/min: 200 mg/day
  • Creatinine clearance <10 mL/min: ≤100 mg/day 4

Advanced therapy options:

For patients refractory to conventional therapy:

• Pegloticase (KRYSTEXXA): 8 mg IV infusion every two weeks 5
  • Indicated for chronic gout refractory to conventional therapy
  • Monitor serum uric acid levels prior to infusions
  • Consider discontinuing if levels increase to above 6 mg/dL, particularly when 2 consecutive elevated levels are observed 5
  • Premedicate with antihistamines and corticosteroids due to risk of anaphylaxis and infusion reactions 5

Key principles for chronic management:

• Titrate allopurinol to achieve target serum uric acid rather than using a fixed dose 1, 4
• Continue urate-lowering therapy during acute flares 1
• Always use prophylactic therapy when initiating urate-lowering therapy 1
• Maintain adequate fluid intake (at least 2 liters daily) 1
• Ensure regular monitoring of serum uric acid levels 4

Lifestyle Modifications

• Reduce excess body weight
• Engage in regular exercise
• Quit smoking
• Avoid excess alcohol
• Avoid sugar-sweetened drinks and high-fructose foods
• Limit purine-rich foods
• Ensure adequate fluid intake (at least 2 liters daily) 1

Common Pitfalls to Avoid

1. Delaying treatment beyond 24 hours of symptom onset
2. Interrupting urate-lowering therapy during acute attacks
3. Inadequate prophylaxis when starting urate-lowering therapy
4. Using fixed-dose allopurinol instead of titrating to target
5. Overlooking comorbidities when selecting therapy 1
6. Failing to monitor serum uric acid levels regularly 4
7. Inadequate patient education about lifestyle modifications 1