What is the diagnosis and treatment for Gout (Gouty Arthritis)?

From the Guidelines

Gout diagnosis and treatment should prioritize urate-lowering therapy (ULT) with allopurinol as the preferred first-line treatment, along with lifestyle modifications and anti-inflammatory medications for acute attacks, as recommended by the 2020 American College of Rheumatology guideline 1.

Diagnosis and Treatment Overview

Gout is a form of inflammatory arthritis caused by high levels of uric acid in the blood, which forms crystals in joints, most commonly affecting the big toe. The diagnosis of gout is based on clinical presentation, laboratory tests, and sometimes imaging studies.

Acute Gout Attack Treatment

Treatment for acute gout attacks includes:

• NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days
• Colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve)
• Corticosteroids like prednisone (30-40mg daily, tapered over 7-10 days) 1

Long-term Management

For long-term management, lifestyle modifications are important:

• Maintaining a healthy weight
• Limiting alcohol (especially beer)
• Avoiding high-purine foods like organ meats and shellfish
• Staying hydrated Medications for preventing future attacks include:
• Allopurinol (starting at 100mg daily, gradually increasing to achieve uric acid levels below 6mg/dL)
• Febuxostat (40-80mg daily) 1 During initiation of these medications, prophylactic colchicine (0.6mg daily) or low-dose NSAIDs may be prescribed for 3-6 months to prevent flares.

Key Recommendations

• Initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 1
• Allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage ≥3) 1
• Using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (≤40 mg/day) 1
• A treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl 1

From the FDA Drug Label

Treatment of gout flares with Colchicine Tablets, USP is not recommended in patients receiving prophylactic dose of Colchicine Tablets, USP and CYP3A4 inhibitors. Gout Flares Prophylaxis of Gout Flares For prophylaxis of gout flares in patients with mild (estimated creatinine clearance [Cl cr] 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine. However, in patients with severe impairment, the starting dose should be 0. 3 mg/day and any increase in dose should be done with close monitoring. For the prophylaxis of gout flares in patients undergoing dialysis, the starting doses should be 0.3 mg given twice a week with close monitoring Treatment of Gout Flares For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine However, in patients with severe impairment, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks.

The diagnosis of Gout (Gouty Arthritis) is not explicitly stated in the provided drug label. The treatment for Gout (Gouty Arthritis) using Colchicine Tablets, USP includes:

• Prophylaxis of Gout Flares:
  • For patients with mild to moderate renal function impairment, the recommended dose does not need to be adjusted, but patients should be monitored closely for adverse effects.
  • For patients with severe renal impairment, the starting dose should be 0.3 mg/day.
  • For patients undergoing dialysis, the starting dose should be 0.3 mg given twice a week.
• Treatment of Gout Flares:
  • For patients with mild to moderate renal function impairment, the recommended dose does not need to be adjusted, but patients should be monitored closely for adverse effects.
  • For patients with severe renal impairment, the treatment course should be repeated no more than once every two weeks.
  • For patients undergoing dialysis, the total recommended dose should be reduced to a single dose of 0.6 mg (one tablet) and the treatment course should not be repeated more than once every two weeks 2.

From the Research

Diagnosis of Gout

• Gout is characterized by painful joint inflammation, most commonly in the first metatarsophalangeal joint, resulting from precipitation of monosodium urate crystals in a joint space 3
• Gout is typically diagnosed using clinical criteria from the American College of Rheumatology 3
• Diagnosis may be confirmed by identification of monosodium urate crystals in synovial fluid of the affected joint 3

Treatment of Acute Gout

• Acute gout may be treated with nonsteroidal anti-inflammatory drugs, corticosteroids, or colchicine 3, 4, 5, 6, 7
• Intra-articular steroids are also suitable for relieving acute arthritis urica 4
• IL-1β antagonists are highly effective for arresting flares but their cost-effectiveness render them salvage therapies 6
• Colchicine, NSAIDs, and oral or intramuscular corticosteroids are standard pharmacotherapies for gout flares 7

Prevention of Recurrent Gout

• To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods and avoid alcoholic drinks and beverages sweetened with high-fructose corn syrup 3
• Consumption of vegetables and low-fat or nonfat dairy products should be encouraged 3
• Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 3, 4, 5, 6, 7
• Uricosuric agents, such as probenecid, can increase uric acid excretion 5, 7
• Novel uricosurics, such as verinurad and arhalofenate, are agents with future promise 6

Urate-Lowering Therapy

• The goal of urate-lowering therapy is to achieve a serum uric acid level below 360 µmol/l ("treat to target") 4
• Allopurinol and febuxostat are xanthine oxidase inhibitors that are effective in reducing uric acid levels 3, 4, 5, 6, 7
• The "start low, go slow" strategy reduces the risk of relapses and the occurrence of hypersensitivity syndrome with allopurinol 4
• Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity significantly threatens the achievement of sustained urate lowering responses 6