What are the treatment options for gout?

Treatment Options for Gout

The management of gout requires a three-pronged approach: treatment of acute flares with oral colchicine, NSAIDs, or glucocorticoids; urate-lowering therapy with medications like allopurinol; and lifestyle modifications to reduce risk factors. 1

Treatment of Acute Gout Flares

First-line Options

• Oral colchicine: Most effective when started within 12 hours of symptom onset

  • Recommended dosing: 1.2 mg initially, followed by 0.6 mg one hour later 1
  • For patients with renal impairment:
    • Mild to moderate impairment: No dose adjustment required but monitor closely
    • Severe impairment: Treatment course should not be repeated more than once every two weeks 2
    • Dialysis patients: Reduced to a single dose of 0.6 mg 2

• NSAIDs:

  • Short-acting NSAIDs like naproxen 500 mg twice daily for 5 days are preferred in elderly patients 1
  • Avoid in patients with eGFR < 30 ml/min or history of peptic ulcer disease/GI bleeding 1

• Corticosteroids:

  • Oral prednisone 30-35 mg daily for 3-5 days 1
  • Particularly recommended for elderly patients due to favorable safety profile 1
  • Intra-articular injections effective for 1-2 large joints 1

Adjunctive Therapy

• Topical ice application 1
• For severe polyarticular involvement, consider combination therapy (e.g., NSAIDs + colchicine) 1

Urate-Lowering Therapy (ULT)

Indications for ULT

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

Medication Options

1. Allopurinol (first-line):

   • Starting dose: 100 mg daily (lower in renal insufficiency)
   • Increase by 100 mg weekly
   • Target serum uric acid level: < 6 mg/dL
   • Typical maintenance dose: 200-600 mg/day depending on severity 1

2. Febuxostat:

   • Alternative first-line if allopurinol is not tolerated or contraindicated 1

3. Probenecid:

   • First choice among uricosurics
   • Can be combined with xanthine oxidase inhibitors for refractory cases 1

Prophylaxis During ULT Initiation

• Colchicine 0.5-1.0 mg daily for first 6 months of ULT to prevent paradoxical flares 1
• Alternative options: low-dose NSAIDs or corticosteroids 3

Lifestyle Modifications

• Weight loss for overweight/obese patients 1
• Dietary 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 1, 3
• Hydration: At least 2 liters daily 1
• Regular moderate physical activity 1

Special Considerations

Renal Impairment

• Assess renal function before initiating therapy 1
• Avoid NSAIDs and colchicine if eGFR < 30 ml/min 1
• For allopurinol in severe renal failure: Start at 0.3 mg/day with careful monitoring 2

Hepatic Impairment

• For mild to moderate impairment: No dose adjustment required for acute treatment, but monitor closely
• For severe impairment: Treatment course should not be repeated more than once every two weeks 2

Pregnancy

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

Common Pitfalls to Avoid

1. Medication interactions: Strong CYP3A4 inhibitors (clarithromycin, ketoconazole) require colchicine dose reductions to prevent toxicity 1

2. Missing early signs of colchicine toxicity: Monitor for gastrointestinal symptoms 1

3. Inadequate monitoring: Regular serum uric acid level checks are necessary to ensure target levels are maintained 1

4. Insufficient duration of ULT: Treatment should continue for at least 3 months after uric acid levels fall below target in those without tophi, and 6 months in those with tophi 3

5. Failure to provide prophylaxis when initiating ULT, which can trigger acute flares 1, 3