What is the recommended management for gout?

Management of Gout

The recommended management for gout includes NSAIDs, low-dose colchicine, or oral corticosteroids as first-line options for acute attacks, with allopurinol as the first-line urate-lowering therapy for long-term management to maintain serum uric acid levels below 6 mg/dL. 1

Acute Gout Management

First-Line Treatment Options

• NSAIDs: First choice for young patients without significant comorbidities due to rapid onset, convenience, and established efficacy 1

  • Begin treatment within 24 hours of symptom onset
  • Contraindicated in patients with cardiovascular disease or heart failure 2

• Low-dose colchicine: Excellent alternative if:

  • Attack caught early (within 36 hours)
  • Patient has contraindications to NSAIDs
  • Previous good response to colchicine 1
  • Dosing: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg over 1 hour) 1
  • Adjust dose for renal impairment:
    • For severe renal impairment: Treatment course should not be repeated more than once every two weeks 3
    • For patients on dialysis: Single dose of 0.6 mg, not repeated more than once every two weeks 3

• Corticosteroids: Consider if:

  • NSAIDs and colchicine are contraindicated
  • Previous attacks responded well to steroids
  • Attack is severe or involves multiple joints 1
  • Options include oral prednisone or intra-articular injections for 1-2 joint involvement 1

Combination Therapy

• For severe acute gout (≥7/10 pain) or polyarticular involvement, consider:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality 1

Treatment Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset 1
• Using high-dose colchicine regimens (continuing until GI side effects develop) 1
• Interrupting urate-lowering therapy during acute attacks 1

Long-Term Management

Urate-Lowering Therapy (ULT)

• Indications for ULT:

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

• First-line ULT: Allopurinol

  • Initial dose: ≤100 mg/day
  • Titrate gradually to achieve target uric acid level <6 mg/dL (or <5 mg/dL in patients with tophi) 1, 4
  • Dosage considerations:
    • Mild gout: 200-300 mg/day
    • Moderate-severe tophaceous gout: 400-600 mg/day
    • Maximum recommended dose: 800 mg/day 4
    • For renal impairment:
      • CrCl 10-20 mL/min: 200 mg/day
      • CrCl <10 mL/min: ≤100 mg/day 4

• Alternative ULT options:

  • Febuxostat: Alternative to allopurinol, but use with caution due to increased cardiovascular risk 1, 2
  • Probenecid: Option for allopurinol-allergic patients with normal renal function and no history of urolithiasis 5
  • Pegloticase: Reserved for patients who have failed other options 1

Prophylaxis When Starting ULT

• Always provide prophylaxis when initiating ULT 1
  • Low-dose colchicine (0.6 mg daily) or
  • Low-dose NSAIDs 1
  • Continue prophylaxis for at least 3-6 months after achieving target uric acid levels 6

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, 6

• 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

• In patients with CVD or heart failure:
  • Avoid NSAIDs due to increased cardiovascular risk 2
  • Prefer colchicine for acute flares (potentially reduces MI risk) 2
  • Use allopurinol as first-line ULT (potential for reducing cardiovascular outcomes) 2
  • Avoid febuxostat due to increased risk of cardiovascular death and heart failure hospitalization 2

Monitoring

• Monitor serum uric acid levels regularly
• Goal: Maintain serum uric acid <6 mg/dL (or <5 mg/dL in severe gout with tophi) 1
• Continue ULT indefinitely to prevent recurrence and improve quality of life 1