What is the management plan for gouty arthritis?

Management Plan for Gouty Arthritis

For acute gout attacks, first-line treatment options include NSAIDs, low-dose colchicine, or oral corticosteroids, with NSAIDs being the preferred option in patients without contraindications. 1

Acute Gout Management

First-Line Options

• NSAIDs: First choice for patients without contraindications due to rapid onset, convenience, and established efficacy
• Low-dose colchicine: Excellent alternative if caught early (within 36 hours)
  • Recommended dosing: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg)
  • Note: High-dose colchicine regimens are no longer recommended
• Corticosteroids: Consider if NSAIDs and colchicine are contraindicated
  • Oral prednisone
  • Intra-articular injections for 1-2 joint involvement

For Severe Attacks

• For severe acute gout (≥7/10 pain) or polyarticular involvement, combination therapy is appropriate 2:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality

For NPO (Nothing by Mouth) Patients

• Intra-articular corticosteroid injections for 1-2 joint involvement 2
• IV/IM methylprednisolone (0.5-2.0 mg/kg initially)
• Subcutaneous ACTH (25-40 IU initially) as an alternative 2

For Inadequate Response to Initial Therapy

• Consider alternative diagnoses if poor response
• Switch to another monotherapy or add a second agent
• For refractory cases, IL-1 inhibitors may be considered (anakinra or canakinumab), though their risk-benefit ratio remains uncertain 2

Long-Term Management

Urate-Lowering Therapy (ULT)

• Goal: Maintain serum uric acid <6 mg/dL (or <5 mg/dL in severe gout with tophi) 1
• First-line agent: Allopurinol
  • Starting dose: 100 mg daily
  • Increase by 100 mg weekly until target uric acid level is achieved
  • Typical dose range: 200-300 mg/day for mild gout, 400-600 mg/day for moderate-severe tophaceous gout 3
  • Maximum recommended dose: 800 mg daily 3
• Dose adjustment for renal impairment 3:
  • CrCl 10-20 mL/min: 200 mg/day
  • CrCl <10 mL/min: ≤100 mg/day
  • CrCl <3 mL/min: Extend dosing interval

Prophylaxis During ULT Initiation

• Critical: Always provide prophylaxis when starting ULT to prevent acute flares 1
• Options:
  • Colchicine 0.6 mg daily (proven effective in clinical trials) 4
  • Low-dose NSAIDs
• Duration: At least 6 months 5

Lifestyle Modifications

• Maintain adequate fluid intake (at least 2 liters daily) 3
• Maintain neutral or slightly alkaline urine 3
• Limit consumption of:
  • Alcohol (especially beer and spirits)
  • Purine-rich foods
  • High-fructose corn syrup
• Encourage:
  • Low-fat dairy products
  • Regular exercise
  • Weight loss for overweight/obese patients 1

Common Pitfalls to Avoid

1. Delayed treatment: Initiate treatment within 24 hours of symptom onset
2. Interrupting ULT during acute attacks: Continue ULT during flares
3. Using fixed-dose allopurinol: Titrate to achieve target serum uric acid levels
4. Inadequate prophylaxis when starting ULT: Always use prophylactic therapy
5. Overlooking renal function: Adjust medication doses in patients with kidney disease 6
6. Using high-dose colchicine: The older regimen of continuing colchicine until GI side effects develop is no longer advised 1

Special Considerations

• Patients with CKD: NSAIDs should be avoided; colchicine requires dose reduction; allopurinol dose must be adjusted based on renal function 6
• Difficult-to-treat gout: Consider referral to rheumatology for patients with frequent flares despite treatment, tophaceous deposits, or contraindications to standard therapies 7