What is the best treatment for gout?

Best Treatment for Gout

For acute gout flares, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs, or oral corticosteroids are strongly recommended as first-line treatments, with selection based on patient comorbidities. 1, 2

Treatment Algorithm for Gout

Acute Gout Flare Management

1. First-line options (start within 24 hours of symptom onset):

   • Low-dose colchicine: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg) 3
   • NSAIDs: Full anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 2
   • Oral corticosteroids: Prednisone 30-35 mg/day for 3-5 days 2

2. Patient-specific considerations:

   • For cardiovascular disease: Prefer colchicine or corticosteroids; avoid NSAIDs 2
   • For renal impairment: Avoid NSAIDs; adjust colchicine dose 2
   • For single joint involvement: Consider intra-articular corticosteroid injection 2

3. Adjunctive therapy:

   • Topical ice application 1, 2

Long-term Management

1. Urate-lowering therapy (ULT) for patients with:

   • Recurrent gout attacks (≥2 per year)
   • Tophi
   • Joint damage
   • Urolithiasis
   • Chronic kidney disease 2

2. First-line ULT:

   • Allopurinol: Start at ≤100 mg/day and gradually titrate to achieve target serum urate level <6 mg/dL (<5 mg/dL for severe gout) 1, 2

3. Alternative ULT options:

   • Febuxostat: When allopurinol is not tolerated or contraindicated (note increased cardiovascular risk) 2
   • Pegloticase: Reserved for severe cases where other ULT options have failed 1, 2

4. Prophylaxis during ULT initiation:

   • Continue for 3-6 months when starting ULT
   • Options include:
     • Colchicine 0.5-0.6 mg once or twice daily
     • Low-dose NSAIDs (e.g., naproxen 250 mg twice daily)
     • Low-dose prednisone (≤10 mg daily) 1, 2

5. Lifestyle modifications:

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

Evidence Quality and Considerations

The evidence for acute gout treatment is robust. Low-dose colchicine has been shown to be as effective as high-dose colchicine with significantly fewer side effects (23% vs. 77% reporting diarrhea) 1. The number needed to treat (NNT) for at least 50% pain relief with colchicine is 3, meaning one in three patients will experience significant pain relief 1.

NSAIDs have similar efficacy to colchicine, with one study showing tenoxicam having an NNT of 3 for achieving more than 50% pain relief 1. Multiple head-to-head comparisons have shown similar efficacy among different NSAIDs 1.

For long-term management, the American College of Rheumatology strongly recommends a treat-to-target approach with ULT to achieve serum urate levels <6 mg/dL 1. This approach has been shown to reduce flare frequency, decrease tophi, and improve quality of life 2.

Common Pitfalls to Avoid

1. Using high-dose colchicine regimens: Low-dose colchicine (1.8 mg total) is equally effective with fewer adverse effects compared to high-dose regimens 1, 3

2. Interrupting ULT during acute flares: Continue ULT during acute attacks 2

3. Inadequate prophylaxis when starting ULT: Always use prophylactic therapy when initiating ULT to prevent flares 2

4. Using fixed-dose allopurinol: Titrate to achieve target serum uric acid levels rather than using a fixed dose 2

5. Delayed treatment of acute flares: Initiate treatment within 24 hours of symptom onset for best results 2

6. Overlooking comorbidities: Consider cardiovascular and renal status when selecting therapy 2

By following this evidence-based approach to gout management, both acute symptoms and long-term complications can be effectively managed, improving patient outcomes and quality of life.