What are the treatment options for acute and chronic gout?

Treatment Options for Acute and Chronic Gout

For acute gout attacks, first-line treatments include oral corticosteroids, NSAIDs, or low-dose colchicine, with treatment selection based on patient comorbidities and timing of symptom onset. 1

Acute Gout Management

First-Line Options

• NSAIDs: Effective for acute gout when no contraindications exist

  • Examples: naproxen, indomethacin 1, 2
  • Caution: Avoid in renal impairment (eGFR < 30 ml/min), history of GI bleeding, or heart failure 1

• Colchicine: Most effective when given within 12 hours of symptom onset

  • Dosing: Low-dose regimen (1.2 mg initially, followed by 0.6 mg after 1 hour) is as effective as high-dose with fewer GI side effects 1
  • Caution: Adjust dose in renal impairment; avoid if eGFR < 30 ml/min 1
  • Monitor for toxicity signs, particularly gastrointestinal symptoms 1

• Oral Corticosteroids: Excellent option when NSAIDs or colchicine are contraindicated

  • Dosing: Prednisolone 30-35 mg daily for 3-5 days 1
  • Particularly useful in patients with renal disease, heart failure, or cirrhosis 1

Alternative Options

• Intra-articular corticosteroid injection: For 1-2 affected joints 1
• Intravenous/intramuscular methylprednisolone: 0.5-2.0 mg/kg 1
• Synthetic ACTH: 25-40 UI subcutaneously 1

Chronic Gout Management (Urate-Lowering Therapy)

Indications for Urate-Lowering Therapy

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

First-Line ULT

• Allopurinol:
  • Initial dose: 100 mg daily (lower in renal insufficiency)
  • Titrate: Increase by 100 mg weekly until target serum urate < 6 mg/dL
  • Maintenance: 200-300 mg/day for mild gout; 400-600 mg/day for moderate-severe tophaceous gout
  • Maximum dose: 800 mg daily 1, 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

  • Caution: Associated with potential cardiovascular risks 1, 4

• Uricosuric agents (probenecid, sulphinpyrazone):

  • Alternative to xanthine oxidase inhibitors
  • Contraindicated in patients with urolithiasis 1

• Benzbromarone: Can be used in mild to moderate renal insufficiency 1

• Pegloticase: Reserved for refractory cases

  • Indicated for chronic gout refractory to conventional therapy
  • Dosing: 8 mg IV every two weeks
  • Monitor serum uric acid levels prior to infusions
  • Consider discontinuing if levels increase above 6 mg/dL, especially with 2 consecutive elevated readings 1, 5

Prophylaxis During ULT Initiation

• Strongly recommended when starting urate-lowering therapy to prevent acute flares 1
• Duration: Continue for 3-6 months after starting ULT or achieving target uric acid levels 1, 6
• Options:
  • Low-dose colchicine (0.5-1.0 mg daily)
  • Low-dose NSAIDs
  • Low-dose prednisone (approximately 7.5 mg daily) 1

Lifestyle Modifications

• Restrict purine-rich foods (organ meats, shellfish), alcohol (especially beer), and high-fructose corn syrup beverages 1, 6
• Increase consumption of low-fat dairy products 1
• Ensure adequate hydration (at least 2 liters daily) 1, 3
• Maintain regular moderate physical activity 1
• Consider discontinuing diuretics if possible 7

Special Considerations

Pregnancy

• Oral, intramuscular, or intra-articular glucocorticoids are preferred for acute attacks 1
• Risk increases in third trimester and postpartum due to estrogen level changes 1

Monitoring

• Before treatment: Assess renal function, gastrointestinal risk factors, and potential drug interactions 1
• During treatment: Monitor serum uric acid levels regularly, aiming for < 6 mg/dL 1
• For colchicine: Watch for early signs of toxicity (gastrointestinal symptoms) 1
• For allopurinol: Start low and go slow, especially in renal impairment 3

Common Pitfalls to Avoid

• Using standard colchicine doses in renal impairment (can lead to severe toxicity) 1
• Failing to provide prophylaxis when initiating ULT 1
• Not considering drug interactions with colchicine (especially P-glycoprotein/CYP3A4 inhibitors) 1
• Discontinuing ULT too early (should be long-term for most patients) 6
• Inadequate dosing of allopurinol (often requires doses higher than 300 mg daily to reach target urate levels) 7