What are the treatment options for gout?

Treatment Options for Gout

The first-line treatment for acute gout flares includes colchicine, NSAIDs, or oral corticosteroids, while allopurinol is the recommended first-line urate-lowering therapy for long-term management to prevent recurrent gout attacks. 1

Acute Gout Management

First-line options:

• Colchicine:

  • Loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 1
  • Dose adjustment required in renal impairment:
    • For severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks 2
    • For dialysis patients: Reduce to single dose of 0.6 mg, not repeated more than once every two weeks 2

• NSAIDs:

  • Equally effective as other options for acute flares 3
  • Avoid in patients with eGFR <30 mL/min 1
  • Consider gastroprotection with PPI if history of peptic ulcer disease 1

• Oral Corticosteroids:

  • Prednisolone 30-35 mg daily for 3-5 days 1
  • Particularly useful in patients with renal disease, heart failure, or cirrhosis 1

Second-line options:

• Intra-articular corticosteroid injection: Effective for involvement of 1-2 joints 1
• IL-1 inhibitors (anakinra or canakinumab): For refractory cases 1
• ACTH: 25-40 IU initially, subcutaneously 1

Long-term Management (Urate-Lowering Therapy)

Indications for ULT:

• Recurrent gout attacks
• Tophi
• Joint damage
• Renal impairment

First-line ULT:

• Allopurinol:
  • Starting dose: 100 mg daily (lower in renal impairment) 1
  • Gradually titrate to target serum urate level <6 mg/dL 1
  • Strong evidence supporting its use as first-line therapy 1, 4

Alternative ULT options:

• Febuxostat:

  • Alternative when allopurinol is not tolerated 1
  • Use with caution due to potential cardiovascular risks 1

• Uricosuric agents:

  • Probenecid, sulfinpyrazone: Alternatives to xanthine oxidase inhibitors 1, 5
  • Contraindicated in patients with urolithiasis 1
  • Benzbromarone: Can be used in mild to moderate renal insufficiency 1

• Pegloticase:

  • Reserved for patients who have failed other options 1
  • Strongly recommended for patients with frequent flares or nonresolving tophi despite other ULT 1

Prophylaxis When Starting ULT

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

Lifestyle Modifications

• Dietary recommendations:

  • Limit purine-rich foods (organ meats, shellfish) 1, 4
  • Avoid alcohol, especially beer 4
  • Avoid high-fructose corn syrup-sweetened beverages 1, 4
  • Increase consumption of low-fat dairy products 1, 4
  • Maintain adequate hydration (at least 2 liters daily) 1

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

Special Considerations

Renal Impairment

• Colchicine: Adjust dose in severe renal impairment 2
• NSAIDs: Avoid if eGFR <30 mL/min 1
• Allopurinol: Start at lower doses and titrate slowly 1

Hepatic Impairment

• Colchicine: Monitor closely; consider dose reduction in severe impairment 2
• For acute flares in severe hepatic impairment: Limit treatment course to no more than once every two weeks 2

Pregnancy

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

Common Pitfalls to Avoid

1. Failure to adjust colchicine dosing in renal impairment, which can lead to severe toxicity 1, 2
2. Missing early signs of colchicine toxicity (gastrointestinal symptoms) 1
3. Not considering drug interactions that can increase colchicine levels 1
4. Discontinuing ULT during acute flares, which can worsen long-term outcomes
5. Inadequate prophylaxis when initiating ULT, leading to increased flare risk 1
6. Failure to titrate allopurinol to achieve target serum urate levels 1

By following these evidence-based treatment approaches, gout can be effectively managed to reduce pain during acute attacks and prevent recurrent flares and complications.