What are the treatment options for gout?

Treatment Options for Gout

The optimal management of gout involves a combination of pharmacological treatments for acute flares and long-term urate-lowering therapy, along with lifestyle modifications to prevent future attacks. 1

Acute Gout Flare Management

First-line Options:

• NSAIDs: Naproxen 500mg twice daily for 5 days

  • Caution: Avoid in renal impairment, peptic ulcer disease, uncontrolled hypertension
  • Use with caution in diabetes or ongoing infection 1

• Colchicine: Start within 36 hours of symptom onset

  • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later
  • Important: Do not use the outdated high-dose regimen (continuing until GI side effects) 1, 2
  • Renal adjustment: For severe impairment, treatment course should not be repeated more than once every two weeks 2
  • For dialysis patients: Reduce to single 0.6 mg dose 2

• Corticosteroids:

  • Oral: Prednisone 30-35 mg daily for 3-5 days
  • Intra-articular: For involvement of 1-2 joints
  • Intramuscular/IV: Methylprednisolone 0.5-2.0 mg/kg 1

For Severe or Refractory Cases:

• Combination therapy: Consider for severe pain (≥7/10) or polyarticular involvement
  • Options: Colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality 1
• IL-1 inhibitors: Anakinra or canakinumab for refractory cases 1
• ACTH: 25-40 IU subcutaneously as an alternative 1

Adjunctive Measures:

• Topical ice application
• Rest and elevation of affected joint 1

Long-term Management

Urate-Lowering Therapy (ULT)

• Indications: Recurrent attacks (≥2 per year), tophaceous gout, chronic kidney disease 1

• First-line: Allopurinol

  • Starting dose: 100 mg daily (lower in renal impairment)
  • Gradually titrate to target serum urate <6 mg/dL 1

• Alternative options:

  • Febuxostat: When allopurinol is not tolerated (caution with cardiovascular risks)
  • Uricosuric agents (probenecid, sulphinpyrazone): Alternative to xanthine oxidase inhibitors
  • Pegloticase: Reserved for patients who failed other options 1

• Important ULT principles:

  • Do not discontinue during acute attacks
  • Provide prophylaxis when initiating ULT (low-dose colchicine or NSAIDs)
  • Adequate dose titration to reach target serum urate 1

Lifestyle Modifications

• Dietary restrictions:

  • Limit purine-rich foods (organ meats, shellfish)
  • Reduce alcohol intake, especially beer
  • Avoid high-fructose corn syrup-sweetened beverages 1, 3

• Recommended intake:

  • Low-fat dairy products
  • Adequate hydration (at least 2 liters daily)
  • Regular, moderate physical activity 1

• Weight management: Weight loss programs if overweight/obese 1

Special Considerations

Renal Impairment

• Acute flares:

  • Mild-moderate impairment: Standard dosing with close monitoring
  • Severe impairment: Limit colchicine treatment course frequency
  • Dialysis: Reduced colchicine dose (0.6 mg single dose) 2

• Prophylaxis:

  • Severe impairment: Start colchicine at 0.3 mg/day
  • Dialysis: 0.3 mg twice weekly 2

Hepatic Impairment

• Acute flares:

  • Mild-moderate impairment: Standard dosing with monitoring
  • Severe impairment: Limit treatment frequency to once every two weeks 2

• Prophylaxis:

  • Consider dose reduction in severe hepatic impairment 2

Common Pitfalls to Avoid

• Discontinuing ULT during acute flares
• Failing to provide prophylaxis when initiating ULT
• Using high-dose colchicine regimens for acute flares
• Stopping prophylaxis too early
• Inadequate dose titration of allopurinol 1
• Delaying treatment beyond 24 hours of symptom onset 1