What is the treatment for a gout flare and which foods high in purines should be avoided?

Treatment of Gout Flares and Foods High in Purines to Avoid

For gout flares, oral colchicine, NSAIDs, or glucocorticoids are strongly recommended as first-line therapy, with the choice based on patient factors and comorbidities, while dietary management should include limiting purine-rich foods such as organ meats, shellfish, and alcohol, particularly beer. 1

First-Line Treatment Options for Acute Gout Flares

Oral Colchicine

• Low-dose colchicine regimen: 1.2 mg initially, followed by 0.6 mg one hour later 2
• Most effective when started within 12 hours of symptom onset
• Strong recommendation for low-dose over high-dose colchicine due to similar efficacy with fewer adverse effects 1
• Contraindications:
  • Severe renal impairment (GFR <30 mL/min) 2
  • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole) 1

NSAIDs

• Recommended regimen: Naproxen 500 mg twice daily for 5 days 2
• Contraindications:
  • History of peptic ulcer disease or GI bleeding (consider PPI if must use) 2
  • Severe renal impairment 2

Glucocorticoids

• Oral regimen: Prednisolone 30-35 mg daily for 5 days 1, 2
• Intra-articular: Particularly effective for 1-2 large joints 2
• Intramuscular/intravenous: Option for patients who cannot take oral medications 1
• Generally safer than NSAIDs in elderly patients or those with comorbidities 2

Combination Therapy for Severe Gout Flares

For particularly severe acute gout involving multiple joints, consider combination therapy such as:

• Colchicine + NSAID
• Colchicine + corticosteroid
• Intra-articular injections with another modality 1, 2

Adjunctive Measures

• Topical ice: Conditionally recommended as an adjuvant treatment 1, 2
• Rest affected joint(s)
• Elevate affected limb

Foods High in Purines to Avoid

The American College of Rheumatology conditionally recommends limiting purine intake for patients with gout 1. Foods high in purines include:

High-Purine Foods (Strongly Avoid)

• Organ meats: Liver, kidney, sweetbreads
• Shellfish: Shrimp, lobster, crab, mussels
• Red meat: Especially game meats
• Alcoholic beverages: Particularly beer 1, 3
• High-fructose corn syrup beverages 1, 3

Moderate-Purine Foods (Limit Consumption)

• Oily fish (sardines, mackerel, anchovies)
• Legumes (beans, lentils)
• Spinach, asparagus, cauliflower
• Mushrooms

Dietary Recommendations

• Encourage consumption of:

  • Low-fat or non-fat dairy products 3
  • Vegetables (despite some having moderate purine content) 3
  • Adequate hydration (at least 2 liters daily) 2

• For overweight/obese patients: Weight loss is conditionally recommended 1, 2

Medication Considerations

• Consider switching hydrochlorothiazide to an alternate antihypertensive when possible 1
• Losartan is preferred as an antihypertensive for gout patients due to its uricosuric effect 1, 3

Monitoring and Follow-up

• Assess renal function before initiating colchicine therapy 4
• Monitor for signs of colchicine toxicity, particularly gastrointestinal symptoms 2
• Consider long-term urate-lowering therapy (allopurinol, febuxostat) for patients with recurrent flares (≥2 per year) 2, 3

Common Pitfalls to Avoid

• Using high-dose colchicine regimens (increased toxicity without improved efficacy) 1
• Not considering drug interactions with colchicine (particularly P-glycoprotein/CYP3A4 inhibitors) 1, 2
• Failing to adjust colchicine dosing in patients with renal impairment 4
• Discontinuing urate-lowering therapy during acute flares (should be continued) 2