What is the recommended treatment for gout?

Treatment of Gout

The recommended treatment for gout includes colchicine, NSAIDs, or glucocorticoids as first-line therapy for acute flares, while long-term management requires urate-lowering therapy (ULT) such as allopurinol with prophylaxis to prevent flares during ULT initiation. 1

Acute Gout Flare Management

First-Line Options

• Colchicine: Low-dose regimen of 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg) 1, 2

  • Must be started within 36 hours of symptom onset for maximum effectiveness
  • Low-dose regimen is strongly recommended over high-dose due to better safety profile 1

• NSAIDs: Any NSAID at full anti-inflammatory doses with appropriate gastroprotection

  • Most convenient option in absence of contraindications

• Glucocorticoids: Oral, intraarticular, or intramuscular options

  • Particularly useful when oral medications cannot be taken 1
  • For 1-2 joint involvement, intra-articular injections are effective

Adjunctive Therapy

• Topical ice application is recommended as an adjuvant treatment 1
• For severe flares (pain ≥7/10) or polyarticular involvement, combination therapy may be appropriate

Second-Line Options

• IL-1 inhibitors when first-line therapies are ineffective, poorly tolerated, or contraindicated 1

Long-Term Management

Urate-Lowering Therapy (ULT)

1. Allopurinol: First-line ULT 1, 3

   • Start at low dose (100 mg daily)
   • Gradually increase by 100 mg every 2-4 weeks until target serum urate level is achieved
   • Dose adjustment required in renal impairment

2. Febuxostat: Alternative when allopurinol is not tolerated

   • Use with caution due to potential cardiovascular risks

3. Uricosuric agents (probenecid, sulphinpyrazone):

   • Alternative to xanthine oxidase inhibitors
   • Contraindicated in patients with urolithiasis
   • Benzbromarone can be used in mild to moderate renal insufficiency 1

4. Pegloticase:

   • Reserved for patients who have failed other options
   • Strongly recommended for patients with frequent flares or nonresolving tophi despite other ULT 1
   • Not recommended for patients with infrequent flares (<2/year) and no tophi 1

Prophylaxis During ULT Initiation

• Colchicine: 0.6 mg once or twice daily for at least 6 months, or 3 months after achieving target serum urate levels in patients without tophi (6 months for those with tophi) 3, 2
• Low-dose NSAIDs with PPI if colchicine is contraindicated
• Low-dose prednisone (<10 mg/day) if both colchicine and NSAIDs are contraindicated 3

Target Serum Urate Level

• Maintain serum uric acid below 6 mg/dL (360 μmol/L) 1, 3
• For severe gout with tophi, target may be lower (<5 mg/dL) 3

Lifestyle Modifications

• Weight loss if obese 1

• Limit consumption of:

  • Alcohol, especially beer 1, 4
  • Purine-rich foods (organ meats, shellfish) 4
  • High-fructose corn syrup 3, 4

• Encourage:

  • Low-fat dairy products 3
  • Adequate fluid intake (at least 2 liters daily) 3
  • Regular exercise 3

Special Considerations

Renal Impairment

• Allopurinol dose must be adjusted based on creatinine clearance 2
• For severe renal impairment, colchicine dosing for acute flares should not be repeated more than once every two weeks 2

Hepatic Impairment

• Monitor patients closely for adverse effects of colchicine
• Consider dose reduction in severe hepatic impairment 2

Drug Interactions

• Colchicine interacts with CYP3A4 and P-glycoprotein inhibitors, requiring dose adjustment 2
• Avoid combining colchicine with statins without careful monitoring for myopathy 3

Common Pitfalls to Avoid

1. Discontinuing ULT during acute flares (should be continued) 3
2. Failing to provide prophylaxis when initiating ULT 3
3. Using high-dose colchicine regimens for acute flares 3
4. Stopping prophylaxis too early (before 6 months or before achieving target urate levels) 3
5. Inadequate dose titration of allopurinol to reach target serum urate levels 5

By following these evidence-based recommendations, gout can be effectively managed and potentially cured through maintaining serum urate at target levels, which resolves urate crystal deposition over time.