What is the treatment for acute gout flare and long-term management of gout?

Treatment of Gout: Acute Flares and Long-term Management

For acute gout flares, first-line treatment options include low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs, or oral corticosteroids, with the choice depending on patient comorbidities and contraindications. 1

Acute Gout Flare Management

First-Line Options:

1. Low-dose colchicine:

   • Dosing: 1.2 mg initially, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2
   • Most effective when started within 12 hours of symptom onset 1
   • Contraindicated in:
     • Severe renal impairment (eGFR <30 ml/min)
     • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors 1, 2

2. NSAIDs:

   • Options include naproxen 500 mg twice daily for 5 days
   • No evidence that indomethacin is more effective than other NSAIDs 3
   • Avoid in patients with renal disease, heart failure, or cirrhosis 3, 4

3. Corticosteroids:

   • Prednisone 30-35 mg daily for 3-5 days 1
   • Preferred in elderly patients and those with cardiovascular disease 1, 4
   • Intra-articular injections effective for 1-2 large joints 1

For Severe Polyarticular Gout:

• Consider combination therapy: colchicine + NSAID, colchicine + corticosteroid, or intra-articular injections with another modality 1

Adjunctive Treatment:

• Topical ice application 1
• Rest of the affected joint 5

Long-term Management of Gout

Urate-Lowering Therapy (ULT):

Initiation Criteria:

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

The American College of Physicians recommends against initiating ULT after a first gout attack or in patients with infrequent attacks. 3

First-Line ULT Options:

1. Allopurinol:

   • Starting dose: 100 mg daily (lower in renal insufficiency)
   • Target serum uric acid level: <6 mg/dL (360 μmol/L) 1
   • Safer option for patients with cardiovascular disease or heart failure 4

2. Febuxostat:

   • Alternative if allopurinol is not tolerated or contraindicated
   • Caution: increased risk of cardiovascular death and heart failure hospitalization 1, 4

Prophylaxis During ULT Initiation:

• Essential to prevent paradoxical flares during first 6 months of ULT 1, 6
• Options:
  • Colchicine 0.5-1.0 mg daily
  • Low-dose NSAIDs
  • Low-dose corticosteroids if other options contraindicated 1, 6

Special Considerations

Cardiovascular Disease:

• Colchicine is preferred for acute flares (potentially reduces MI risk) 4
• Avoid NSAIDs 4
• Allopurinol preferred for ULT 4

Renal Impairment:

• For severe impairment (eGFR <30 ml/min):
  • Avoid colchicine and NSAIDs
  • Use reduced doses of corticosteroids
  • For ULT, start allopurinol at lower doses (e.g., 50 mg daily) 1, 2

Hepatic Impairment:

• For severe impairment:
  • Consider dose reduction for colchicine
  • Limit treatment courses for acute flares to no more than once every two weeks 2

Lifestyle Modifications

• Limit purine-rich foods (organ meats, shellfish, red meat)
• Reduce alcohol intake, particularly beer
• Limit high-fructose corn syrup beverages
• Increase consumption of low-fat dairy products
• Maintain adequate hydration (at least 2 liters daily)
• Weight loss for overweight/obese patients
• Regular moderate physical activity 1

Common Pitfalls to Avoid

1. Using high-dose colchicine regimens (associated with increased gastrointestinal adverse effects) 3
2. Failing to provide prophylaxis when initiating ULT
3. Starting ULT at high doses (increases risk of acute flares)
4. Discontinuing ULT during acute flares
5. Using NSAIDs in patients with cardiovascular disease or renal impairment
6. Not adjusting medication doses in patients with organ dysfunction

Remember that treatment success depends largely on how quickly therapy is initiated for acute flares and consistent adherence to ULT for long-term management 5.