What are the treatment options for managing gout?

Comprehensive Management of Gout

The management of gout requires a dual approach focusing on treating acute flares with anti-inflammatory medications (colchicine, NSAIDs, or corticosteroids) and preventing future attacks through urate-lowering therapy (ULT) with medications like allopurinol, along with lifestyle modifications. 1, 2

Acute Gout Flare Management

First-Line Treatment Options

• Treat acute flares as early as possible with one of the following first-line options:

1. Colchicine:

   • Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 3
   • Most effective when started within 12 hours of symptom onset 1
   • Contraindicated in severe renal impairment and with strong P-glycoprotein/CYP3A4 inhibitors 3

2. NSAIDs:

   • Options include naproxen 500mg twice daily 2
   • Use with proton pump inhibitor if GI risk factors present 2
   • Avoid in severe renal impairment 1

3. Corticosteroids:

   • Oral: Prednisone 30-35 mg daily for 3-5 days 1, 2
   • Intra-articular injection: Particularly effective for 1-2 large joints 2

Special Considerations

• For patients with contraindications to colchicine, NSAIDs, and corticosteroids, IL-1 blockers may be considered 1
• For severe polyarticular gout, combination therapy may be used (e.g., NSAIDs + colchicine) 2
• In renal impairment (eGFR <30 ml/min):
  • Avoid colchicine and NSAIDs 2
  • Use corticosteroids as preferred treatment 2
  • If colchicine must be used, reduce dose to 0.3 mg/day 3

Long-Term Management and Prevention

Urate-Lowering Therapy (ULT)

• Indications for ULT:

  • Recurrent gout attacks (≥2 per year)
  • Presence of tophi
  • Joint damage
  • Chronic kidney disease 2

• First-line ULT:

  • Allopurinol: Start at 100 mg daily (lower in renal insufficiency) 2
  • Target serum uric acid level below 6 mg/dL (360 μmol/L) 1
  • Adjust dose gradually to achieve target 1

• Alternative ULT options:

  • Febuxostat: Alternative to allopurinol, but associated with increased cardiovascular risk 4
  • Uricosuric drugs (e.g., probenecid): Option for allopurinol-allergic patients with normal renal function 5

Flare Prophylaxis During ULT Initiation

• Prophylaxis is essential during the first 6 months of ULT to prevent paradoxical flares 1
• Options include:
  • Colchicine: 0.5-1.0 mg daily (reduce dose in renal impairment) 1, 3
  • Low-dose NSAIDs (if not contraindicated) 2
  • Low-dose prednisone (approximately 7.5 mg daily) 2

Lifestyle Modifications

• Dietary recommendations:
  • Limit purine-rich foods (organ meats, shellfish)
  • Avoid alcohol (especially beer) and beverages with high-fructose corn syrup
  • Increase consumption of low-fat dairy products
  • Ensure adequate hydration (at least 2 liters daily) 2
• Weight loss if overweight/obese 1
• Regular moderate physical activity 2

Monitoring and Follow-up

• Monitor serum uric acid levels regularly to ensure target levels are maintained 1
• Assess renal function before initiating therapy and periodically during treatment 2
• Check for drug interactions, particularly with colchicine (P-glycoprotein/CYP3A4 inhibitors) 2
• Monitor for signs of colchicine toxicity (gastrointestinal symptoms) 2

Common Pitfalls to Avoid

• Failing to provide prophylaxis when initiating ULT (leads to increased flares) 1
• Underdosing ULT (not achieving target serum uric acid levels) 1
• Not considering drug interactions with colchicine (can lead to toxicity) 2
• Discontinuing ULT prematurely (should be lifelong in most cases) 1
• Treating without patient education about the disease and importance of adherence 1

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