What are the management options for gout (gouty arthritis)?

From the Guidelines

The management of gout should prioritize urate-lowering therapy (ULT) for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares, with allopurinol as the preferred first-line ULT, as recommended by the 2020 American College of Rheumatology guideline 1.

Management Options

The management of gout involves both acute treatment of flares and long-term prevention strategies. For acute gout attacks, the following options are available:

• Colchicine, which is effective when started early (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve) 1
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen or indomethacin, for 3-5 days 1
• Glucocorticoids (oral, intraarticular, or intramuscular) for patients with contraindications to NSAIDs or colchicine 1

Long-term Management

For long-term management, the following strategies are recommended:

• Lifestyle modifications, including weight loss if overweight, limiting alcohol (especially beer), avoiding high-purine foods (organ meats, shellfish, red meat), and staying well-hydrated 1
• Urate-lowering therapy (ULT) is indicated for patients with frequent attacks, tophi, joint damage, or kidney stones, with a treat-to-target management strategy and ULT dose titration guided by serial serum urate measurements, aiming for a target of <6 mg/dL 1
• Allopurinol as the preferred first-line ULT, starting at a low dose (≤100 mg/day, and lower in patients with moderate-to-severe chronic kidney disease) and gradually increasing to achieve the target serum uric acid level 1
• Febuxostat as an alternative for those who cannot tolerate allopurinol, starting at a low dose (≤40 mg/day) 1

Preventing Flares

When initiating ULT, concomitant anti-inflammatory prophylaxis therapy, such as colchicine (0.6mg daily) or low-dose NSAIDs, should be given for at least 3-6 months to prevent flares 1

From the FDA Drug Label

The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis

The management options for gout (gouty arthritis) include:

• Allopurinol: to lower serum uric acid levels, with dosages varying from 100 to 800 mg daily, depending on the severity of the disease 2
• Colchicine: to suppress gouty attacks, used prophylactically when starting allopurinol therapy 2 2
• Anti-inflammatory agents: such as indomethacin, to relieve pain, reduce fever, swelling, redness, and tenderness of acute gouty arthritis 2 3

From the Research

Management Options for Gout

The management of gout involves both the treatment of acute gouty attacks and the long-term reduction of serum uric acid levels to prevent future attacks.

• Acute Gout Treatment: The options for treating acute gout include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 4, 5, 6, 7, 8
  • Colchicine 4, 5, 6, 7, 8
  • Corticosteroids 4, 5, 6, 7, 8
  • IL-1 inhibitors for flare refractory to standard therapies 5
• Urate-Lowering Therapies: These aim to prevent gout flares by reducing serum uric acid levels, with an emphasis on a treat-to-target strategy:
  • Allopurinol 6, 7
  • Febuxostat 5, 6, 7
  • Uricosuric agents such as probenecid, sulfinpyrazone, and benzbromarone 5, 6, 7
  • Emerging therapies in development 5
• Prophylaxis: Considered an adjunct to long-term urate-lowering therapy to prevent acute flares, especially when initiating urate-lowering therapy 6, 8
• Personalization of Treatment: Adjusting pharmacotherapy based on comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 5