What are the treatment options for managing gout?

Gout Management

The management of gout requires a three-pronged approach: treating acute flares with NSAIDs, colchicine, or corticosteroids; initiating urate-lowering therapy for recurrent attacks; and providing prophylaxis during ULT initiation to prevent flares. 1

Acute Gout Management

First-line options:

• NSAIDs:

  • Naproxen 500 mg twice daily
  • Indomethacin 50 mg three times daily
  • Ibuprofen 800 mg three times daily
  • Avoid in patients with cardiovascular disease, heart failure, or severe renal impairment 1, 2

• Colchicine:

  • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later 1, 3
  • Maximum dose for acute treatment: 1.8 mg over a one-hour period 3
  • Preferred in patients with cardiovascular disease 2
  • Dose adjustment required for renal impairment and drug interactions 3

• Corticosteroids:

  • Oral prednisone 30-35 mg/day for 3-5 days 1
  • Intra-articular injection for monoarticular gout 1
  • Consider for patients who cannot tolerate colchicine and have contraindications to NSAIDs 1, 2

Adjunctive measures:

• Topical ice application 1
• Rest of the affected joint 4

Urate-Lowering Therapy (ULT)

Indications for ULT:

• Recurrent attacks (≥2 per year)
• Tophaceous gout
• Chronic kidney disease 1

Treatment options:

1. Allopurinol (first-line):

   • Initial dose ≤100 mg/day
   • Titrate gradually to achieve target uric acid level (<6 mg/dL, or <5 mg/dL in severe gout) 1
   • Safe in patients with cardiovascular disease or heart failure 2
   • Dose adjustment required in renal impairment 1

2. Febuxostat (alternative):

   • Use with caution due to increased risk of cardiovascular mortality and heart failure hospitalization 1, 2
   • Not preferred in patients with cardiovascular disease 2

3. Probenecid (uricosuric):

   • Alternative for allopurinol-allergic patients
   • Best for underexcretors with normal renal function and no history of urolithiasis 4
   • Safe in patients with cardiovascular disease 2

4. Pegloticase:

   • Reserved for patients who have failed other options
   • Recommended for frequent attacks or persistent tophi 1
   • Use with caution in cardiovascular disease due to increased risk of cardiovascular events 2

Prophylaxis During ULT Initiation

Prophylactic options:

• Low-dose colchicine (0.6 mg once or twice daily, maximum 1.2 mg/day) 1, 3
• Low-dose NSAIDs
• Low-dose prednisone 1

Duration:

• Continue for at least 3-6 months or until target urate level is achieved 1
• For patients with tophi, continue for at least 6 months after uric acid levels normalize 5

Lifestyle Modifications

Dietary recommendations:

• Limit consumption of:

  • Alcohol (especially beer and spirits)
  • Purine-rich foods (organ meats, shellfish)
  • High-fructose corn syrup
  • Excessive meat intake 1

• Encourage:

  • Low-fat dairy products
  • Adequate fluid intake (at least 2 liters daily)
  • Regular exercise
  • Weight loss program for overweight/obese patients 1

Special Considerations

Cardiovascular Disease:

• Prefer colchicine or corticosteroids for acute flares 1, 2
• Avoid NSAIDs 2
• Prefer allopurinol or probenecid for ULT 2
• Avoid febuxostat and pegloticase if possible 2

Renal Impairment:

• Adjust colchicine dosing:
  • For severe impairment (CrCl <30 mL/min): start with 0.3 mg/day 3
  • For dialysis patients: 0.3 mg twice weekly 3
• Avoid NSAIDs 1
• Adjust allopurinol dosing based on renal function 1

Drug Interactions:

• Reduce colchicine dose when used with CYP3A4 or P-glycoprotein inhibitors 1, 3
• Consider discontinuing diuretics if possible 1
• Losartan may be beneficial for hypertensive patients with gout 1, 5

Common Pitfalls to Avoid

1. Using high-dose colchicine (associated with more adverse effects) 1
2. Starting ULT during an acute attack without appropriate prophylaxis 1
3. Overlooking renal function when prescribing NSAIDs or colchicine 1
4. Delaying treatment of acute flares (should initiate within 24 hours) 1
5. Interrupting ULT during acute attacks (should be continued) 1
6. Using fixed-dose allopurinol (should titrate to target uric acid levels) 1
7. Overlooking comorbidities when selecting therapy 1