What are the treatment options for gout?

Gout Treatment Options

The optimal treatment approach for gout includes colchicine, NSAIDs, or oral corticosteroids for acute flares, and allopurinol as the first-line urate-lowering therapy for long-term management, with a treat-to-target strategy aiming for serum uric acid levels below 6 mg/dL. 1

Acute Gout Flare Management

First-Line Options

• Colchicine: Most effective when started within 12 hours of symptom onset

  • Dosing: 1.2 mg loading dose, followed by 0.6 mg one hour later on day 1, then 0.5-1 mg daily until attack resolves 1
  • Dose adjustment required in renal impairment: For severe renal impairment, treatment course should not be repeated more than once every two weeks 2

• NSAIDs: Full anti-inflammatory doses until attack resolves

  • Examples: naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or ibuprofen 800 mg three times daily 1
  • Caution: Avoid in patients with cardiovascular disease or renal impairment 3

• Corticosteroids: Particularly appropriate for patients with cardiovascular comorbidities

  • Oral: Prednisone 30-35 mg/day for 3-5 days 1
  • Intra-articular: Highly effective for monoarticular gout 1

Adjunctive Therapy

• Topical ice application: Conditionally recommended to help reduce pain and inflammation 1
• Combination therapy: Consider for severe or polyarticular attacks
  • Options include NSAID + colchicine, oral corticosteroid + colchicine, or intra-articular corticosteroid + systemic therapy 1

Long-Term Management

Urate-Lowering Therapy (ULT)

Indications for ULT (strong recommendations) 4:

• Tophaceous gout
• Radiographic damage due to gout
• Frequent gout flares (≥2 per year)

First-Line ULT:

• Allopurinol: Strongly recommended as first-line therapy, even in patients with moderate-to-severe chronic kidney disease 4
  • Starting dose: ≤100 mg/day (lower in CKD)
  • Gradually titrate dose every 2-4 weeks to achieve target serum urate level 1
  • Target: Serum uric acid <6 mg/dL (<5 mg/dL for severe gout) 1

Alternative ULT Options:

• Febuxostat: Alternative when allopurinol is not tolerated or contraindicated

  • Starting dose <40 mg/day 4
  • Caution: Increased risk of cardiovascular death and heart failure hospitalization 3

• Uricosuric agents (e.g., probenecid, sulphinpyrazone):

  • Can be used as alternatives to allopurinol in patients with normal renal function 4
  • Contraindicated in patients with urolithiasis 4
  • Benzbromarone can be used in mild to moderate renal insufficiency but carries risk of hepatotoxicity 4

• Pegloticase: Reserved for patients where other ULT options have failed 1

  • Strongly recommended when other ULTs have failed in patients with frequent flares or nonresolving tophi 4
  • Strongly recommended against in patients with infrequent flares (<2/year) and no tophi 4

Flare Prophylaxis During ULT Initiation

• Prophylaxis is strongly recommended for at least 3-6 months when starting ULT 4, 1
• Options include:
  • Colchicine 0.5-1 mg daily
  • Low-dose NSAIDs (with gastroprotection if indicated)
  • Low-dose prednisone (≤10 mg daily) 1

Lifestyle Modifications

• Weight loss if obese 4, 1
• Dietary changes:
  • Limit alcohol intake, especially beer 4, 1
  • Avoid sugar-sweetened beverages and high-fructose foods 1
  • Limit purine-rich foods (organ meats, shellfish) 1, 5
  • Encourage vegetable consumption and low-fat dairy products 5
• Adequate hydration: At least 2 liters of fluid daily 1
• Regular exercise 1

Special Considerations

Patients with Cardiovascular Disease

• Preferred acute treatment: Colchicine (may reduce risk of myocardial infarction) or short-duration low-dose corticosteroids 3
• Avoid NSAIDs in patients with cardiovascular disease or heart failure 3
• Preferred ULT: Allopurinol or probenecid (potential for reducing cardiovascular outcomes) 3
• Avoid febuxostat due to increased risk of cardiovascular death 3

Patients with Renal Impairment

• Colchicine: Dose adjustment required in severe renal impairment 2
• Allopurinol: Start at lower doses (≤100 mg/day) and titrate carefully 1
• Avoid NSAIDs in severe renal impairment 1

Common Pitfalls to Avoid

1. Delayed treatment initiation: Start treatment within 24 hours of symptom onset 1
2. Interrupting ULT during acute flares: Continue ULT during acute attacks 1
3. Inadequate prophylaxis when starting ULT: Always use prophylactic therapy when initiating ULT 1
4. Using fixed-dose allopurinol: Titrate to achieve target serum uric acid levels 1
5. Overlooking drug interactions: Colchicine interacts with CYP3A4 and P-glycoprotein inhibitors 1