What is the management and treatment of acute gout?

Management and Treatment of Acute Gout

For acute gout attacks, first-line treatment options include NSAIDs (such as naproxen 500mg twice daily for 5 days), low-dose colchicine (1.2mg initially followed by 0.6mg one hour later), or corticosteroids, with treatment selection based on patient comorbidities and contraindications. 1

Acute Gout Treatment Algorithm

First-Line Options (choose based on patient factors):

1. NSAIDs

   • Naproxen 500mg twice daily for 5 days
   • Contraindications: Renal impairment, peptic ulcer disease, uncontrolled hypertension
   • Use with caution: Diabetes, ongoing infection 1

2. Colchicine

   • Start within 36 hours of symptom onset
   • Low-dose regimen: 1.2mg initially followed by 0.6mg one hour later
   • Better safety profile than older high-dose regimens
   • Note: The older regimen of continuing colchicine until GI side effects develop is no longer advised 1

3. Corticosteroids

   • Options include:
     • Oral prednisone 30-35mg daily for 3-5 days
     • Intra-articular injections for 1-2 affected joints
     • Methylprednisolone IV/IM at 0.5-2.0mg/kg
   • Particularly useful when NSAIDs and colchicine are contraindicated 1

For Severe Acute Gout (≥7/10 pain or polyarticular):

• Consider combination therapy:
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality 1

For Refractory Cases:

• IL-1 inhibitors (anakinra or canakinumab)
• Subcutaneous ACTH (25-40 IU initially) 1

Adjunctive Measures:

• Topical ice application
• Rest and elevation of affected joint
• Adequate hydration (at least 2 liters daily) 1

Long-Term Management

Urate-Lowering Therapy (ULT)

Allopurinol is the first-line agent for ULT with these guidelines:

• Starting dose: 100mg daily (lower in renal impairment)
• Gradual titration: Increase by 100mg weekly
• Target serum urate level: <6mg/dL
• Dosage range: 200-300mg/day for mild gout; 400-600mg/day for moderately severe tophaceous gout 1, 2

Important: When starting ULT, continue prophylaxis with low-dose colchicine or NSAIDs for at least 8 weeks (ideally 3-6 months after achieving target uric acid levels) to prevent acute flares 1

Alternative ULT options:

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

Indications for Long-Term ULT:

• Recurrent attacks (≥2 per year)
• Tophaceous gout
• Chronic kidney disease
• Recurrent calcium oxalate stones in hyperuricosuric patients 1, 2

Lifestyle Modifications

• Dietary restrictions:

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

• Encourage:

  • Low-fat dairy products
  • Adequate fluid intake (≥2 liters daily)
  • Regular, moderate physical activity
  • Weight loss if overweight/obese 1

Common Pitfalls to Avoid

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

Special Considerations

Renal Impairment

• With creatinine clearance 10-20 mL/min: Allopurinol 200mg daily
• With creatinine clearance <10 mL/min: Allopurinol ≤100mg daily
• With extreme renal impairment (clearance <3 mL/min): Consider extending interval between doses 2

Monitoring

• Use serum uric acid level as an index for dosage adjustment
• Monitor renal function, especially in patients with pre-existing renal disease 2

The management of gout requires both acute treatment of flares and long-term prevention strategies. By following this evidence-based approach, clinicians can effectively control symptoms, prevent recurrent attacks, and improve patients' quality of life.