What are the treatment options for gout?

Treatment Options for Gout

The treatment of gout should follow a two-pronged approach: management of acute flares with NSAIDs, colchicine, or corticosteroids, and long-term urate-lowering therapy with allopurinol as first-line treatment to prevent recurrent attacks and complications. 1

Acute Gout Management

First-line Options:

• NSAIDs:

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

• Colchicine:

  • Low-dose regimen: 1mg loading dose followed by 0.5mg one hour later on day 1
  • Comparable efficacy to high-dose regimens with significantly fewer adverse effects (23% vs 77% diarrhea) 1
  • Dose adjustments for renal impairment:
    • Mild to moderate impairment: No adjustment needed but monitor closely
    • Severe impairment: Treatment course should not be repeated more than once every two weeks
    • Dialysis patients: Single dose of 0.6mg, not repeated more than once every two weeks 2

• Corticosteroids:

  • Oral prednisolone 30-35mg daily for 3-5 days
  • Particularly useful in patients with renal disease, heart failure, or cirrhosis 1
  • Intra-articular injection for involvement of 1-2 joints 1

Second-line Options:

• IL-1 inhibitors (anakinra or canakinumab) for refractory cases 1
• Subcutaneous ACTH (25-40 IU initially) as an alternative 1

Long-term Management

Urate-Lowering Therapy (ULT):

• Target serum urate level: <6 mg/dL for patients with recurrent gout attacks 1

• First-line agent: Allopurinol

  • Starting dose: 100mg daily (lower in renal impairment)
  • Gradually titrate to achieve target serum urate level <6 mg/dL
  • Effective for preventing future attacks and reducing complications 1

• Alternative agents:

  • Febuxostat: When allopurinol is not tolerated (use with caution due to potential cardiovascular risks)
  • Uricosuric agents (probenecid, sulphinpyrazone): Alternative to xanthine oxidase inhibitors
    • Contraindicated in patients with urolithiasis
  • Benzbromarone: Can be used in mild to moderate renal insufficiency
  • Pegloticase: Reserved for patients who have failed other options, especially those with frequent flares or nonresolving tophi 1

Prophylaxis During ULT Initiation:

• Low-dose colchicine (0.6mg once or twice daily) or NSAIDs for at least 8 weeks
• Continue for 3-6 months after achieving target uric acid levels 1

Lifestyle Modifications

• Dietary recommendations:

  • Limit purine-rich foods (organ meats, shellfish)
  • Avoid alcohol, especially beer
  • Avoid beverages sweetened with high-fructose corn syrup
  • Increase consumption of low-fat dairy products
  • Maintain adequate hydration (at least 2 liters daily) 1, 3

• Physical activity: Regular, moderate exercise tailored to individual capabilities 1

Special Considerations

Renal Impairment:

• Acute flares: Corticosteroids preferred in severe renal impairment 1, 2
• ULT: Allopurinol starting dose should be reduced in renal impairment 1, 2

Hepatic Impairment:

• Acute flares: No dose adjustment needed for mild to moderate impairment; for severe impairment, treatment course should not be repeated more than once every two weeks 2
• ULT: Consider dose reduction in severe hepatic impairment 2

Pregnancy:

• Oral, intramuscular, or intra-articular glucocorticoids are recommended for acute gout attacks 1

Common Pitfalls to Avoid

1. Delayed treatment - Prompt treatment is crucial for therapeutic success 1
2. Inadequate diagnosis - Confirm diagnosis with monosodium urate crystal identification when possible 3
3. Failure to consider renal function when dosing medications 1, 2
4. Not providing prophylaxis when initiating ULT 1
5. Inappropriate medication combinations - Consider drug interactions, especially with colchicine and P-glycoprotein/CYP3A4 inhibitors 1
6. Inadequate duration of ULT - Treatment should continue for at least 3 months after uric acid levels fall below target in those without tophi, and 6 months in those with tophi 3

By following these evidence-based recommendations, gout can be effectively managed to reduce pain during acute attacks and prevent long-term complications through appropriate urate-lowering therapy.