What are the treatment options for managing gout?

Gout Management: Treatment Options

The treatment of gout should follow a three-pronged approach: managing acute attacks with NSAIDs, corticosteroids, or colchicine; initiating urate-lowering therapy with allopurinol as first-line treatment; and providing prophylaxis during ULT initiation with low-dose colchicine or NSAIDs to prevent flares. 1

Acute Gout Attack Management

First-Line Options

• NSAIDs: Full FDA-approved anti-inflammatory doses (e.g., naproxen 500mg twice daily, indomethacin 50mg three times daily) until attack resolves 1
• Colchicine: 1.2mg (two tablets) at first sign of flare, followed by 0.6mg (one tablet) one hour later, with maximum dose of 1.8mg over a one-hour period 2
• Oral corticosteroids: Prednisone 30-35mg/day for 3-5 days 1
• Intra-articular corticosteroid injections: Particularly effective for involvement of 1-2 joints 3

Treatment Selection Based on Patient Factors

• For patients with cardiovascular disease: Prefer colchicine or short-duration corticosteroids; avoid NSAIDs 4
• For patients with renal impairment: Avoid NSAIDs; adjust colchicine dosing based on renal function 2
• For polyarticular attacks: Consider combination therapy (NSAID + colchicine, oral corticosteroid + colchicine) 1

Important Timing Considerations

• Initiate treatment within 24 hours of symptom onset 3
• Colchicine is most effective when started within 12 hours of symptom onset 1
• Continue established urate-lowering therapy during acute attacks 3, 1

Urate-Lowering Therapy (ULT)

First-Line Treatment

• Allopurinol: Start at ≤100mg/day and gradually titrate to achieve target serum urate level of <6mg/dL (<5mg/dL for severe gout) 1
• Appropriate even in patients with moderate-to-severe chronic kidney disease 1

Alternative ULT Options

• Febuxostat: When allopurinol is not tolerated or contraindicated, but note increased risk of cardiovascular death 1
• Probenecid: Alternative for patients with normal renal function who cannot tolerate allopurinol 1
• Pegloticase: Reserved for patients where other ULT options have failed 1

Indications for ULT

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

Prophylaxis During ULT Initiation

Recommended Prophylactic Regimens

• Colchicine: 0.5-0.6mg once or twice daily (maximum 1.2mg/day) 3, 2
• Low-dose NSAIDs: Such as naproxen 250mg twice daily 3
• Low-dose prednisone: ≤10mg daily when colchicine or NSAIDs are contraindicated 1

Duration of Prophylaxis

• Continue for at least 3-6 months after starting ULT 1
• Continue until there is no clinical evidence of gout disease activity AND serum urate target has been achieved 3
• For patients without tophi: continue for at least 3 months after achieving target serum urate 3
• For patients with tophi: continue for at least 6 months after achieving target serum urate and resolution of tophi 3

Lifestyle Modifications

• Limit alcohol intake, especially beer 1
• Reduce purine-rich food consumption (organ meats, shellfish) 5
• Avoid sugar-sweetened beverages and high-fructose foods 1
• Weight loss if obese 1
• Regular exercise 1
• Adequate fluid intake (at least 2 liters daily) 1

Common Pitfalls to Avoid

• Delaying treatment: Initiate treatment within 24 hours of symptom onset 1
• Interrupting ULT during acute attacks: Continue ULT during flares 3, 1
• Inadequate prophylaxis: Always use prophylactic therapy when initiating ULT 1
• Using fixed-dose allopurinol: Titrate to achieve target serum urate levels 1
• Overlooking comorbidities: Consider cardiovascular and renal status when selecting therapy 1, 4
• Drug interactions: Adjust colchicine dose when used with CYP3A4 or P-glycoprotein inhibitors 2

Special Considerations

Renal Impairment

• For acute gout with severe renal impairment: Treatment course should not be repeated more than once every two weeks 2
• For patients on dialysis: Reduce colchicine to 0.6mg single dose for acute treatment 2
• For ULT in severe renal failure: Start allopurinol at lower doses (e.g., 50mg) and titrate slowly 1

Hepatic Impairment

• Monitor closely for adverse effects of colchicine 2
• For severe hepatic impairment: Consider dose reduction and limit treatment frequency 2

By following these evidence-based recommendations, clinicians can effectively manage gout, prevent recurrent attacks, and minimize long-term complications while considering patient-specific factors and comorbidities.