What is the recommended management for gout?

Management of Gout

The recommended management of gout includes treating acute flares with oral colchicine, NSAIDs, or glucocorticoids as first-line therapy, followed by urate-lowering therapy with allopurinol as the preferred agent, targeting serum uric acid levels below 6 mg/dL, while addressing lifestyle factors and comorbidities. 1

Acute Gout Flare Management

First-line Treatment Options

• Initiate treatment within 24 hours of symptom onset 2
• Choose from:
  • Colchicine: 1.2 mg initially, followed by 0.6 mg one hour later (low-dose regimen) 1, 2, 3
  • NSAIDs: Naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or ibuprofen 800 mg three times daily 1, 2
  • Glucocorticoids: Oral prednisone 30-35 mg/day for 3-5 days, or intra-articular injection for monoarticular involvement 1, 2

Treatment Selection Considerations

• Patient factors should guide treatment choice:
  • For patients with cardiovascular disease: Prefer colchicine or corticosteroids 2, 4
  • For patients with renal impairment: Avoid NSAIDs and adjust colchicine dosing 2, 3
  • For patients on P-glycoprotein/CYP3A4 inhibitors: Avoid colchicine or reduce dose 2, 3
  • For patients who cannot take oral medications: Use parenteral glucocorticoids 1

Adjunctive Therapy

• Topical ice application can provide additional relief 1, 2
• Consider joint aspiration and injection of corticosteroids for monoarticular gout 1

Long-term Management

Urate-Lowering Therapy (ULT)

• Indications for ULT:

  • Recurrent acute attacks (≥2 per year)
  • Tophaceous gout
  • Radiographic damage due to gout
  • Urolithiasis
  • Chronic gouty arthritis 1, 5

• First-line ULT:

  • Allopurinol starting at ≤100 mg/day (lower in CKD) 1, 2, 6
  • Gradually increase by 100 mg every 2-4 weeks 6
  • Target serum uric acid level <6 mg/dL (<5 mg/dL in severe/tophaceous gout) 1, 2

• Alternative ULT options:

  • Febuxostat: Alternative to allopurinol, but use with caution in patients with cardiovascular disease 2, 4
  • Probenecid: Option for patients who cannot tolerate xanthine oxidase inhibitors 5, 4

Prophylaxis During ULT Initiation

• Always provide prophylaxis when starting ULT to prevent flares 1, 2
• Options include:
  • Colchicine 0.5-1 mg/day (adjusted for renal function)
  • Low-dose NSAIDs with gastroprotection if appropriate
  • Low-dose prednisone if other options contraindicated 1, 2
• Continue prophylaxis for at least 3-6 months or until target urate level is achieved 2, 5

Lifestyle Modifications

Dietary Recommendations

• Limit consumption of:
  • Alcohol, especially beer and spirits 1, 2
  • Purine-rich foods (organ meats, shellfish) 1, 2, 5
  • High-fructose corn syrup 2
  • Excessive meat intake 1
• Encourage:
  • Low-fat dairy products 1, 5
  • Adequate fluid intake (at least 2 liters daily) 2
  • Regular exercise 1, 2

Weight Management

• Weight loss program for overweight/obese patients 1, 2

Management of Comorbidities

• Screen for and address associated conditions:

  • Hypertension
  • Hyperlipidemia
  • Diabetes/insulin resistance
  • Chronic kidney disease
  • Cardiovascular disease 1

• Medication considerations:

  • Consider discontinuing diuretics if possible 1, 5
  • Losartan may be beneficial for hypertensive patients with gout 5

Common Pitfalls to Avoid

1. Delaying treatment of acute flares (should be initiated within 24 hours) 2
2. Interrupting ULT during acute attacks (should be continued) 2
3. Using fixed-dose allopurinol without titration to target uric acid level 2, 6
4. Inadequate prophylaxis when initiating ULT 2
5. Overlooking renal function when dosing colchicine and allopurinol 3, 6
6. Using NSAIDs in patients with cardiovascular disease or renal impairment 2, 4

By following these evidence-based recommendations, healthcare providers can effectively manage gout, reduce the frequency and severity of flares, prevent long-term complications, and improve patients' quality of life.