What are the diagnosis and management strategies for gout (gouty arthritis)?

From the Guidelines

Gout is diagnosed through a combination of clinical presentation, laboratory findings, and joint fluid analysis, and its management involves both acute treatment and long-term prevention, with a focus on urate-lowering therapy and lifestyle modifications, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Diagnosis

The definitive diagnosis of gout requires identification of monosodium urate crystals in synovascular fluid or tophi.

• Clinical presentation: sudden onset of intense pain, swelling, and redness in a joint, typically the big toe
• Laboratory findings: elevated serum uric acid levels, although not always present during an acute attack
• Joint fluid analysis: identification of monosodium urate crystals in synovial fluid

Acute Treatment

For acute gout attacks, the following treatments are recommended:

• NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days
• Colchicine (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve) is effective if started within 24 hours of symptom onset
• Corticosteroids, either oral prednisone (30-40mg daily for 3-5 days with taper) or intra-articular injection, are alternatives for patients who cannot take NSAIDs or colchicine

Long-term Management

For long-term management, the following strategies are recommended:

• Lifestyle modifications: weight loss, limiting alcohol and purine-rich foods, and adequate hydration
• Urate-lowering therapy: indicated for patients with frequent attacks, tophi, joint damage, or serum uric acid >9mg/dL
• Allopurinol (starting at 100mg daily and titrating up to 300-600mg daily) or febuxostat (40-80mg daily) are first-line agents, aiming for a serum uric acid level below 6mg/dL
• Prophylaxis with low-dose colchicine (0.6mg daily) or NSAIDs during the first 3-6 months of urate-lowering therapy is recommended to prevent flares that can occur with initial treatment
• Regular monitoring of serum uric acid levels and kidney function is essential for effective management, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage. An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets, even when normal or subnormal serum uric acid levels have been attained. Accordingly, maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun The diagnosis and management strategies for gout (gouty arthritis) include:

• Medication: allopurinol tablets to lower serum uric acid levels
• Dosing: start with a low dose (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained
• Prophylaxis: maintenance doses of colchicine to prevent acute gouty attacks
• Monitoring: serum uric acid levels and renal function
• Lifestyle modifications: high fluid intake, neutral or slightly alkaline urine, and dietary changes (e.g., reduction of animal protein, sodium, refined sugars, oxalate-rich foods, and excessive calcium intake) 2 2

From the Research

Diagnosis of Gout

• Gout is a common inflammatory arthritis caused by the deposition of monosodium urate crystals in articular and non-articular structures 3
• Diagnosis requires synovial fluid analysis with direct visualization of monosodium urate crystals 3
• A presumptive diagnosis of gout can be made clinically based on the presence of hyperuricemia, rapid development of pain, tenderness, and swelling in a single joint, and family history 4

Management of Acute Gout

• Non-steroidal anti-inflammatory drugs, colchicine, and corticosteroids are options for the management of acute gout, and are equally efficacious 5
• Standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 6
• Acute flares are managed with steroids, non-steroidal anti-inflammatory drugs, or colchicine 3

Long-term Management of Gout

• Urate-lowering therapy (ULT) is indicated in patients with 2 or more gout flares/year, tophi, or radiographic evidence of gouty arthropathy 3
• Allopurinol is an effective treatment for reducing concentrations of uric acid, and is the first-line ULT agent 5, 3
• Febuxostat is another xanthine oxidase inhibitor, and is clinically equivalent to allopurinol 5, 3
• Uricosuric drugs, such as probenecid, increase uric acid excretion, and are effective options for ULT 5, 3
• Lifestyle modifications, including weight loss, avoidance of alcohol, purine-rich foods, and diuretics, are also important for long-term management of gout 3, 4

Treatment Goals

• The goal of ULT is to achieve serum uric acid levels below 6 mg/dL, although a lower target of less than 5 mg/dL may be implemented in patients with tophi 3
• Treatment should be individualized, taking into account comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 6