Gout Treatment: Management of Acute and Chronic Disease
For gout management, NSAIDs, low-dose colchicine, or corticosteroids are first-line treatments for acute flares, while allopurinol is the preferred urate-lowering therapy for chronic gout with a target serum urate level below 6 mg/dL. 1
Acute Gout Management
First-Line Options
NSAIDs (e.g., naproxen, indomethacin): Effective for acute gout flares 1, 2
- Caution in patients with renal disease, heart failure, or GI risk factors
- Avoid in patients with eGFR < 30 ml/min 1
Colchicine: Use low-dose regimen (1.2 mg initially, followed by 0.6 mg after 1 hour) 1
Corticosteroids: Excellent alternative when NSAIDs/colchicine are contraindicated 1
- Oral: Prednisolone 30-35 mg daily for 3-5 days
- Intra-articular injection: Option for 1-2 affected joints
- Parenteral: Methylprednisolone 0.5-2.0 mg/kg IV/IM
- Synthetic ACTH: 25-40 UI subcutaneously
Important Cautions
- Never combine NSAIDs and colchicine due to synergistic GI toxicity 1
- Consider alternative diagnoses if inadequate response to initial therapy 1
- Joint aspiration with synovial fluid analysis is the reference standard for diagnosis when clinically indicated 1
Chronic Gout Management (Urate-Lowering Therapy)
Indications for Urate-Lowering Therapy (ULT)
- Recurrent gout attacks (≥2 per year)
- Presence of tophi
- Evidence of joint damage
- Chronic kidney disease
- Urolithiasis 1
First-Line ULT
- Allopurinol: Start at 100 mg daily (lower in renal insufficiency) 1, 3
- Increase by 100 mg weekly until target serum uric acid < 6 mg/dL is reached
- Usual dose: 200-300 mg/day for mild gout, 400-600 mg/day for moderate-severe tophaceous gout 3
- Maximum dose: 800 mg daily 3
- Dose adjustment for renal impairment:
- CrCl 10-20 mL/min: 200 mg/day
- CrCl < 10 mL/min: ≤ 100 mg/day
- CrCl < 3 mL/min: Consider extending dosing interval 3
Alternative ULT Options
Febuxostat: Alternative when allopurinol is not tolerated
- Use with caution due to potential cardiovascular risks 1
Uricosuric agents (probenecid, sulphinpyrazone):
- Alternative to xanthine oxidase inhibitors
- Contraindicated in urolithiasis 1
Pegloticase: Reserved for refractory cases 1, 4
- Indicated for chronic gout refractory to conventional therapy
- Administered as 8 mg IV infusion every two weeks
- Monitor serum uric acid levels prior to infusions
- Consider discontinuation if levels increase above 6 mg/dL, especially with two consecutive elevated readings 4
- Premedicate with antihistamines and corticosteroids due to risk of anaphylaxis and infusion reactions 4
Prophylaxis During ULT Initiation
- Low-dose colchicine or NSAIDs for at least 8 weeks when starting ULT
- Continue for 3-6 months after achieving target uric acid levels 1
- Prevents acute flares during ULT initiation
Lifestyle Modifications
- Restrict purine-rich foods (organ meats, shellfish), alcohol (especially beer), and high-fructose corn syrup beverages 1
- Increase consumption of low-fat dairy products 1
- Maintain adequate hydration (at least 2 liters daily) 1
- Engage in regular moderate physical activity 1
Monitoring
- Assess renal function before initiating therapy 1
- Target serum urate level < 6 mg/dL for patients with recurrent gout attacks 1
- Continue monitoring serum uric acid levels to ensure therapeutic targets are maintained
- Evaluate for drug interactions, particularly with colchicine (P-glycoprotein/CYP3A4 inhibitors, statins) 1