What are the treatment options for gout?

Gout Treatment Options

For acute gout flares, first-line treatment options include NSAIDs, low-dose colchicine, or corticosteroids, while long-term management requires urate-lowering therapy with allopurinol or febuxostat for patients with recurrent attacks, tophi, or joint damage. 1

Acute Gout Management

First-Line Options

1. NSAIDs (e.g., naproxen, indomethacin)

   • Effective for acute gout flares
   • Contraindications: renal impairment, history of peptic ulcer disease, heart failure
   • Consider gastroprotection with PPI if GI risk factors present

2. Colchicine

   • Most effective when given within 12 hours of symptom onset
   • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg after 1 hour
   • Dosing adjustments for 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
   • Common side effects: gastrointestinal symptoms (diarrhea, nausea, vomiting)

3. Corticosteroids

   • Oral: Prednisolone 30-35 mg daily for 3-5 days 1
   • Intra-articular: Option for 1-2 affected joints
   • Parenteral: Methylprednisolone 0.5-2.0 mg/kg IV/IM
   • Particularly useful in patients with renal disease, heart failure, or cirrhosis

Pitfall to avoid: Using standard colchicine doses in patients with renal impairment can lead to severe toxicity. Always check renal function before prescribing and adjust dosing accordingly. 1, 2

Long-Term Management

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:

1. Allopurinol

   • Starting dose: 100 mg daily (lower in renal insufficiency)
   • Titrate to achieve serum urate level <6 mg/dL
   • Dose adjustments needed for renal impairment

2. Febuxostat (alternative when allopurinol not tolerated)

   • Use with caution due to potential cardiovascular risks
   • Not routinely recommended due to increased all-cause and cardiovascular mortality 3

3. Uricosuric agents (third-line options)

   • Probenecid: effective when CrCl >50 mL/min
   • Benzbromarone: can be used in mild to moderate renal insufficiency
   • Contraindicated in patients with urolithiasis

4. Pegloticase (reserved for refractory cases)

   • For patients with frequent flares or nonresolving tophi despite other ULT
   • Not recommended for patients with infrequent flares (<2/year) and no tophi

Important: When initiating ULT, prophylaxis with low-dose colchicine or NSAIDs for at least 8 weeks is recommended to prevent acute flares. 1

Lifestyle Modifications

• 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
• Maintain adequate hydration (at least 2 liters daily)
• Regular moderate physical activity
• Weight loss if overweight/obese

Special Populations

Renal Impairment

• For prophylaxis in severe renal impairment: start colchicine at 0.3 mg/day 2
• For dialysis patients: colchicine 0.3 mg twice weekly 2
• Allopurinol dose should be reduced based on renal function

Hepatic Impairment

• For severe hepatic impairment: consider dose reduction for prophylaxis
• For acute flares: treatment course should not be repeated more than once every two weeks 2

Pregnancy

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

Monitoring

• Assess renal function before initiating therapy
• Target serum urate level <6 mg/dL for patients with recurrent attacks
• Continue ULT for at least 3 months after achieving target uric acid levels (6 months if tophi present) 4
• Monitor for colchicine toxicity, especially in patients with renal impairment
• Check for drug interactions, particularly with P-glycoprotein/CYP3A4 inhibitors and statins

Caution: Failing to recognize early signs of colchicine toxicity (gastrointestinal symptoms) can have severe consequences. Monitor patients closely, especially those with renal or hepatic impairment. 1