From the Guidelines
Gout treatment should prioritize urate-lowering therapy (ULT) with allopurinol as the first-line option, along with lifestyle modifications and anti-inflammatory prophylaxis for acute attacks, as recommended by the 2020 American College of Rheumatology guideline 1.
Treatment Options for Gout
The management of gout involves both immediate relief for acute attacks and long-term management to prevent recurrences. For acute gout attacks, the following options are recommended:
- Colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily) is effective when started early but can cause gastrointestinal side effects.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (500mg twice daily) or indomethacin (50mg three times daily) are first-line treatments, typically continued for 7-10 days.
- Glucocorticoids (oral, intraarticular, or intramuscular) are options for patients who can't take NSAIDs or colchicine.
Long-term Management
For long-term management, urate-lowering therapy is recommended for patients with frequent attacks or tophi. The following options are recommended:
- Allopurinol (starting at 100mg daily, gradually increasing to 300-600mg daily) as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage ≥3) 1.
- Febuxostat (40-80mg daily) is an alternative option for patients who cannot tolerate allopurinol.
- A treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl, is recommended 1.
Lifestyle Modifications
Lifestyle modifications are also important, including:
- Weight loss if overweight
- Limiting alcohol (especially beer)
- Reducing intake of purine-rich foods like red meat and seafood
- Staying well-hydrated These treatments work by either reducing inflammation during acute attacks or lowering uric acid levels to prevent crystal formation in joints, which causes the painful inflammation characteristic of gout.
Key Recommendations
- Initiate ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares 1.
- Use a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (≤40 mg/day) 1.
- Concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months is strongly recommended when initiating ULT 1.
From the FDA Drug Label
Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis. Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis For prophylaxis of gout flares in patients with mild (estimated creatinine clearance Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine.
The treatment options for gout (gouty arthritis) include:
- Colchicine for prophylaxis of gout flares and treatment of gout flares
- Indomethacin for relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis
- Probenecid for the treatment of the hyperuricemia associated with gout and gouty arthritis 2, 3, 4
From the Research
Treatment Options for Gout
The treatment of gout includes several options, which can be categorized into anti-inflammatory therapy, prophylaxis of flare-ups, and measures for long-term uric acid reduction.
- Anti-inflammatory therapy:
- Prophylaxis of flare-ups:
- Long-term uric acid reduction:
- Xanthine oxidase inhibitors, such as allopurinol and febuxostat, are the main pillar of gout therapy 5, 6, 7
- The goal is to achieve a serum uric acid level below 360 µmol/l ("treat to target") 5
- Allopurinol is started at a low dose (maximum 100 mg/d) and titrated upwards, while febuxostat is started at a maximum of 40 mg/d and also titrated upwards 5
- Lesinurad, in combination with xanthine oxidase inhibitors, is a new treatment option for patients with refractory gout 8
- IL-1 inhibitors, such as canakinumab, are also effective for the treatment of acute gout attacks, especially in subjects refractory to NSAIDs and/or colchicine 7, 9
Considerations for Treatment
Comorbidities, such as chronic kidney disease and ischemic heart disease, should be taken into account when selecting a treatment option 7 Patient education and counseling, as well as regular laboratory follow-up, are important components of gout treatment 8