What is the recommended treatment for chronic gout?

Chronic Gout Treatment

For chronic gout management, urate-lowering therapy (ULT) with allopurinol is strongly recommended as first-line treatment, starting at a low dose (≤100 mg/day, lower in chronic kidney disease) with gradual titration to achieve a serum urate target of <6 mg/dL. 1

Indications for Urate-Lowering Therapy

Strong indications for initiating ULT include:

• Tophaceous gout
• Radiographic damage due to gout
• Frequent gout flares (≥2 per year)
• Chronic kidney disease stage ≥3
• History of urolithiasis

Treatment Algorithm

First-Line ULT

• Allopurinol: Strongly recommended as first-line agent for all patients, including those with CKD stage ≥3 1
  • Starting dose: ≤100 mg/day (lower in CKD)
  • Gradually titrate dose based on serum urate levels
  • Maximum FDA-approved dose: 800 mg/day 2
  • Consider HLA-B*5801 testing before starting allopurinol in patients of Southeast Asian descent (Han Chinese, Korean, Thai) 1, 3

Alternative ULT Options

• Febuxostat: For patients who cannot tolerate allopurinol

  • Starting dose: ≤40 mg/day
  • Titrate up to 80 mg daily as needed
  • Use with caution in patients with cardiovascular disease 1, 3

• Probenecid: Consider when xanthine oxidase inhibitors fail or are contraindicated

  • Starting dose: 500 mg once or twice daily
  • Less effective in patients with renal impairment (CrCl <50 ml/min) 1, 3

• Pegloticase: Reserved for patients with refractory chronic gout who have failed or cannot tolerate oral ULT options 3, 4

  • Administered as 8 mg IV infusion every 2 weeks
  • Monitor serum uric acid levels before each infusion
  • Consider discontinuation if levels increase above 6 mg/dL on two consecutive measurements 4

Treat-to-Target Approach

• Target serum urate level: <6 mg/dL for most patients 1, 3
• Lower target (<5 mg/dL): Consider for patients with severe gout or tophaceous disease 3
• Monitoring: Check serum urate every 2-4 weeks during dose titration, then every 6 months once target is achieved 3
• Duration: ULT should be continued indefinitely in most cases 1

Flare Prophylaxis

• Strongly recommended when initiating ULT to prevent flares 1
• Options:
  • Colchicine (preferred if no contraindications)
  • NSAIDs
  • Low-dose prednisone/prednisolone
• Duration: Continue for at least 3-6 months after achieving target urate level 1, 5

Acute Flare Management

Strong recommendations for acute gout flares include:

• Colchicine: Most effective when started early in an attack
• NSAIDs: Consider patient's comorbidities
• Glucocorticoids: Oral, intraarticular, or intramuscular options 1, 3

Lifestyle Modifications

• Weight loss if overweight
• Limit alcohol consumption (especially beer and spirits)
• Avoid sugar-sweetened beverages and high-fructose corn syrup
• Limit purine-rich foods (organ meats, shellfish)
• Encourage low-fat dairy products
• Maintain adequate hydration (at least 2 liters daily) 3, 5, 6

Important Clinical Considerations

• ULT can be initiated during an acute flare if adequate anti-inflammatory treatment is provided 1
• Long-term ULT has been shown to reduce flare frequency to nearly zero when serum urate is maintained at target levels 7
• Tophi resolution improves with sustained ULT (46% resolution with febuxostat 80 mg, 36% with febuxostat 120 mg, and 29% with allopurinol) 7
• Avoid asymptomatic hyperuricemia treatment unless specific indications exist 3

By following this evidence-based approach to chronic gout management, focusing on appropriate ULT selection, treat-to-target strategy, and lifestyle modifications, patients can achieve significant reductions in flare frequency and improved quality of life.