What are the treatment options for gout?

Gout Treatment Options

For acute gout flares, first-line treatment includes NSAIDs, low-dose colchicine (1.2 mg initially, followed by 0.6 mg after 1 hour), or corticosteroids, with treatment selection based on patient comorbidities and contraindications. 1

Acute Gout Management

First-Line Options

• NSAIDs (naproxen, indomethacin)

  • Effective for acute flares
  • Avoid in patients with renal impairment, heart failure, peptic ulcer disease, or GI bleeding 1
  • Consider gastroprotection with PPI in high-risk patients

• Colchicine

  • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg after 1 hour
  • As effective as high-dose with fewer GI side effects
  • Dose adjustments 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: reduced to single dose of 0.6 mg, not repeated more than once every two weeks 2
  • Monitor for early signs of toxicity (gastrointestinal symptoms) 1
  • Avoid combining with NSAIDs due to synergistic GI toxicity 1

• Corticosteroids

  • Oral: Prednisolone 30-35 mg daily for 3-5 days
  • Intra-articular injection for 1-2 affected joints
  • Methylprednisolone IV/IM at 0.5-2.0 mg/kg
  • Good option for patients with renal disease, heart failure, or cirrhosis 1

• Synthetic ACTH

  • Subcutaneous administration at 25-40 UI initially 1

Long-Term Management

Urate-Lowering Therapy (ULT)

Indications for ULT:

• Recurrent gout attacks (≥2 per year)
• Presence of tophi
• Joint damage
• Chronic kidney disease or urolithiasis 1

Treatment Options:

1. Allopurinol (First-line)

   • Initial dose: 100 mg daily (lower in renal insufficiency)
   • Titrate to achieve target serum urate <6 mg/dL 1
   • Dose should be tailored according to renal function

2. Febuxostat (Alternative)

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

3. Uricosuric Agents

   • Probenecid, sulphinpyrazone
   • Contraindicated in urolithiasis
   • Benzbromarone can be used in mild to moderate renal insufficiency 1

4. Pegloticase

   • Reserved for treatment failures
   • Strongly recommended for patients with frequent flares or nonresolving tophi despite other ULT 1

Prophylaxis When Starting ULT

• Low-dose colchicine or NSAIDs for at least 8 weeks
• Continue for 3-6 months after achieving target uric acid levels 1

Lifestyle Modifications

• Dietary Restrictions:

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

• Dietary Recommendations:

  • Increase low-fat dairy products
  • Ensure adequate hydration (at least 2 liters daily)
  • Regular moderate physical activity 1

Special Considerations

Renal Impairment

• Assess renal function before initiating therapy
• Avoid NSAIDs and use colchicine with caution if eGFR <30 ml/min
• Consider reduced doses of colchicine if eGFR 30-60 ml/min 1, 2

Hepatic Impairment

• For 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
• For prophylaxis: Consider dose reduction in severe hepatic impairment 2

Pregnancy

• Oral, intramuscular, or intra-articular glucocorticoids are recommended
• Options include prednisone 30-35 mg daily for 3-5 days or intra-articular injections 1

Common Pitfalls to Avoid

1. Failure to confirm diagnosis - Joint aspiration with synovial fluid analysis for monosodium urate crystals is the reference standard 1

2. Inappropriate colchicine dosing - Using standard doses in renal impairment can lead to severe toxicity 1, 2

3. Missing drug interactions - Check for P-glycoprotein/CYP3A4 inhibitors and concurrent statin therapy 1

4. Inadequate prophylaxis - Not providing prophylaxis when initiating ULT can trigger flares 1

5. Insufficient ULT dose titration - Failure to titrate allopurinol to achieve target serum urate levels 1