What are the treatment options for gout?

Treatment Options for Gout

The management of gout includes both acute flare treatment and long-term urate-lowering therapy, with NSAIDs, colchicine, and corticosteroids being first-line options for acute flares, while allopurinol is the preferred first-line agent for long-term management. 1

Acute Gout Management

First-line Options

• NSAIDs (naproxen, indomethacin)

  • Effective for acute flares
  • Contraindicated in renal disease, heart failure, or history of GI bleeding 1
  • Avoid in patients with eGFR <30 ml/min 1

• Low-dose Colchicine

  • Dosing: 1.2 mg initially, followed by 0.6 mg after 1 hour
  • As effective as high-dose regimens with fewer GI side effects 1
  • Dose adjustments required in renal impairment:
    • For severe renal impairment: 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

• Corticosteroids

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

Important Caution

• Never combine NSAIDs and colchicine due to synergistic gastrointestinal toxicity 1

Long-term Urate-Lowering Therapy (ULT)

Indications for ULT

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

First-line ULT

• Allopurinol
  • Initial dose: 100 mg daily (lower in renal insufficiency)
  • Titrate to target serum urate <6 mg/dL 1
  • Dosage should be tailored according to renal function 1, 3

Alternative ULT Options

• Febuxostat

  • Alternative when allopurinol is not tolerated
  • Use with caution due to potential cardiovascular risks 1, 4

• Uricosuric Agents

  • Probenecid: Alternative to xanthine oxidase inhibitors
  • Contraindicated in patients with urolithiasis
  • Effective when creatinine clearance >50 mL/min 1, 5

• Pegloticase

  • Reserved for patients who have failed other options
  • Strongly recommended for patients with frequent flares or nonresolving tophi 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, 6

Lifestyle Modifications

• Dietary Recommendations

  • Restrict 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
  • Ensure adequate hydration (at least 2 liters daily) 1, 6

• Other Modifications

  • Regular moderate physical activity
  • Weight loss if overweight/obese 1

Special Considerations

Renal Impairment

• Adjust colchicine dosing in severe renal impairment (CrCl <30 mL/min)
• For prophylaxis in severe renal impairment: Start at 0.3 mg/day 2
• For dialysis patients: Start at 0.3 mg twice weekly 2

Hepatic Impairment

• Monitor closely for adverse effects of colchicine
• Consider dose reduction for prophylaxis in severe hepatic impairment
• For acute flares in severe hepatic impairment: Do not repeat treatment course more than once every two weeks 2

Pregnancy

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

Common Pitfalls to Avoid

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

2. Inappropriate colchicine use in renal impairment: Can lead to severe toxicity even at low doses; requires careful dosing and monitoring 1, 2

3. Missing drug interactions: Particularly with colchicine and P-glycoprotein/CYP3A4 inhibitors or statins 1

4. Inadequate prophylaxis when starting ULT: Failure to provide prophylaxis can lead to increased flares 1

5. Insufficient ULT dosing: Many patients require higher than standard doses of allopurinol to reach target urate levels 5

6. Discontinuing medications too early: ULT should continue for at least 3 months after reaching target uric acid levels (6 months if tophi are present) 6