What is the workup and management of gout?

Workup and Management of Gout

The management of gout should follow a treat-to-target approach with urate-lowering therapy (ULT), starting with allopurinol as first-line therapy, aiming for serum uric acid levels below 6 mg/dL, while treating acute flares with colchicine, NSAIDs, or corticosteroids. 1

Diagnostic Workup

Definitive Diagnosis

• Identification of monosodium urate (MSU) crystals in synovial fluid is the gold standard for definitive diagnosis 1
• If crystal identification is not possible, diagnosis can be supported by:
  • Classical clinical features (podagra, tophi, rapid response to colchicine)
  • Characteristic imaging findings 1

Laboratory Testing

• Serum uric acid level (hyperuricemia typically >6.8 mg/dL)
• Renal function tests (creatinine, BUN)
• Assessment of cardiovascular risk factors 1

Management of Acute Gout Flares

First-Line Options (choose based on comorbidities)

1. Low-dose colchicine:

   • Preferred regimen: 1.2 mg initially, followed by 0.6 mg one hour later 1, 2
   • Maximum 2 mg daily 1
   • Dose reduction required in renal impairment 2
   • For severe renal failure (CrCl <30 mL/min): start with 0.3 mg/day 2

2. NSAIDs:

   • Full anti-inflammatory doses
   • Avoid in patients with renal impairment, history of GI bleeding, or cardiovascular disease 1

3. Corticosteroids:

   • Options include oral, intramuscular, or intra-articular administration
   • Particularly useful when NSAIDs and colchicine are contraindicated 1

Alternative for Refractory Cases

• IL-1 inhibitors can be considered in patients with contraindications to colchicine, NSAIDs, and corticosteroids 1

Long-Term Management

Indications for Urate-Lowering Therapy (ULT)

ULT should be initiated for patients with:

• Tophaceous gout (strong recommendation) 1
• Radiographic damage due to gout (strong recommendation) 1
• Frequent gout flares (≥2 per year) 1
• Chronic kidney disease 1, 3
• History of urolithiasis 4

First-Line ULT

Allopurinol:

• Start at low dose: 100 mg/day (lower in CKD) 1, 5
• Titrate dose by 100 mg increments every 2-4 weeks 3, 5
• Target serum uric acid <6 mg/dL (<5 mg/dL in severe/tophaceous gout) 1, 3
• Typical maintenance dose: 200-300 mg/day for mild gout; 400-600 mg/day for moderate-severe tophaceous gout 5
• Maximum dose: 800 mg/day 5
• For CKD patients:
  • CrCl 10-20 mL/min: 200 mg/day
  • CrCl <10 mL/min: ≤100 mg/day 5

Alternative ULT Options (if allopurinol fails or is not tolerated)

1. Febuxostat:

   • Start at <40 mg/day and titrate upward 1
   • Note: Associated with increased cardiovascular mortality compared to allopurinol 4

2. Uricosurics (probenecid, benzbromarone):

   • Start probenecid at 500 mg once or twice daily 1
   • Benzbromarone is more effective than allopurinol but may be hepatotoxic 1

3. Combination therapy:

   • Xanthine oxidase inhibitor plus uricosuric 1

4. Pegloticase:

   • Reserved for refractory tophaceous gout when other ULTs have failed 1

Prophylaxis When Starting ULT

• Mandatory anti-inflammatory prophylaxis for 3-6 months when initiating ULT 1, 3
• Options include:
  • Low-dose colchicine (0.5-1.2 mg daily) 1, 3
  • Low-dose NSAIDs with gastroprotection 3
  • Low-dose prednisone/prednisolone 1

Lifestyle and Dietary Modifications

Recommended Changes

• Weight loss if overweight/obese (aim for 5kg reduction) 3
• Regular exercise (avoid strenuous exercise during flares) 3
• Adequate hydration (>2L water daily) 3
• Increase consumption of low-fat dairy products 3
• Consider vegetable protein as alternative to animal protein 3
• Cherries may help reduce frequency of acute attacks 3

Foods/Beverages to Limit or Avoid

• Red meat (limit to 5-7 servings per week) 3
• Organ meats 3
• Seafood 3, 6
• Alcohol, especially beer 3, 6
• Sugar-sweetened beverages and fruit juices (especially with high-fructose corn syrup) 3, 6

Monitoring and Follow-up

• Regular monitoring of serum uric acid levels until target is achieved 1, 3
• Monitor frequency of gout attacks 1
• Measure tophi size if present 1
• Assess medication adherence at each visit 3
• Evaluate and manage comorbidities (hypertension, diabetes, hyperlipidemia, kidney disease) 1, 3

Special Considerations

Renal Impairment

• Avoid NSAIDs 3
• Adjust colchicine dosing (see above) 2
• Adjust allopurinol dosing based on creatinine clearance 5
• Consider febuxostat or benzbromarone as alternatives 1

Cardiovascular Disease

• Consider replacing diuretics with alternative medications when possible 3
• Consider losartan for hypertension management due to its uricosuric effects 3
• For hyperlipidemia, consider fenofibrate due to its modest uricosuric effects 3

Diabetes

• Monitor glucose levels carefully when using corticosteroids 3
• Be aware that male sex, renal impairment, and diuretic use are major risk factors for gout in diabetic patients 3