What are the treatment options for acute and chronic gout management?

Treatment and Diagnosis for Gout

For acute gout flares, first-line treatment is NSAIDs, colchicine, or oral corticosteroids, with colchicine being most effective when given within 12 hours of symptom onset at a low-dose regimen of 1.2 mg initially followed by 0.6 mg one hour later. 1

Diagnosis of Gout

• Joint aspiration with identification of monosodium urate crystals in synovial fluid is the gold standard for diagnosis
• Clinical criteria from the American College of Rheumatology can be used when joint aspiration is not feasible
• Typical presentation includes:
  • Sudden onset of severe joint pain (often first metatarsophalangeal joint)
  • Erythema, swelling, and warmth over affected joint
  • Elevated serum uric acid (though not always present during acute attacks)

Treatment of Acute Gout Flares

First-Line Options:

1. NSAIDs:

   • Effective for acute gout when started early 1
   • Options include naproxen, indomethacin, or other NSAIDs
   • Contraindicated in patients with renal impairment (eGFR < 30 ml/min), history of peptic ulcer disease, or GI bleeding 1

2. Colchicine:

   • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later (maximum 1.8 mg in one hour) 1
   • Most effective when given within 12 hours of symptom onset
   • Reduce dose in renal impairment (avoid if eGFR < 30 ml/min)
   • Check for drug interactions with CYP3A4 inhibitors 1

3. Oral Corticosteroids:

   • Prednisolone 30-35 mg daily for 3-5 days 1
   • Particularly useful in patients with contraindications to NSAIDs or colchicine
   • For severe cases requiring hospitalization, methylprednisolone IV may be considered 1

Special Populations:

• Pregnancy: Oral, intramuscular, or intra-articular glucocorticoids are recommended as the best treatment option 1
• Renal Impairment: Avoid NSAIDs and colchicine if eGFR < 30 ml/min; consider reduced doses of colchicine if eGFR 30-60 ml/min 1

Management of Chronic Gout (Urate-Lowering Therapy)

Indications for ULT 1:

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

First-Line ULT:

1. Allopurinol:

   • Start at 100 mg daily (lower in renal insufficiency)
   • Increase by 100 mg weekly until target serum uric acid < 6 mg/dL is achieved 1, 2
   • Maintenance dose typically 200-300 mg/day for mild gout, 400-600 mg/day for moderate-severe tophaceous gout 2
   • Maximum recommended dose is 800 mg daily 2
   • Adjust dose based on renal function:
     • Creatinine clearance 10-20 mL/min: 200 mg/day
     • Creatinine clearance < 10 mL/min: ≤ 100 mg/day 2

2. Alternative ULT options:

   • Febuxostat: Alternative when allopurinol is not tolerated (use with caution due to cardiovascular risks) 1
   • Uricosuric agents (probenecid, sulphinpyrazone): Alternative to xanthine oxidase inhibitors, contraindicated in urolithiasis 1
   • Benzbromarone: Can be used in mild to moderate renal insufficiency 1

Prophylaxis During ULT Initiation:

• Prophylaxis against acute flares is strongly recommended when starting ULT 1
• Continue prophylaxis for 3-6 months after starting ULT 1
• Options include:
  • Low-dose colchicine (0.5-1.0 mg daily)
  • Low-dose NSAIDs
  • Low-dose prednisone (approximately 7.5 mg daily) 1

Lifestyle Modifications

• Restrict dietary intake of purine-rich foods (organ meats, shellfish)
• Avoid alcohol (especially beer) and beverages sweetened with high-fructose corn syrup
• Increase consumption of low-fat dairy products
• Ensure adequate hydration (at least 2 liters daily)
• Engage in regular moderate physical activity 1

Common Pitfalls to Avoid

1. Failure to provide prophylaxis when initiating ULT, which can trigger acute flares
2. Not considering drug interactions with colchicine (especially CYP3A4 inhibitors)
3. Inappropriate dosing of allopurinol without consideration of renal function
4. Stopping ULT during acute flares, which can worsen long-term outcomes
5. Not targeting serum uric acid levels below 6 mg/dL for effective prevention of recurrent attacks

By following this comprehensive approach to gout management, focusing on both acute treatment and long-term prevention, patients can achieve significant reduction in flare frequency and improved quality of life.