What are the management options for gout, including both chronic and acute flares?

Management of Gout: Acute Flares and Chronic Therapy

NSAIDs, colchicine, or corticosteroids should be used as first-line treatments for acute gout flares, while urate-lowering therapy with allopurinol should be initiated for patients with recurrent gout attacks, tophi, or joint damage. 1

Acute Gout Management

First-Line Options for Acute Flares

The choice of first-line therapy depends on patient comorbidities and contraindications:

1. Low-dose 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 (total 1.8 mg over 1 hour) 2
   • Avoid high-dose regimens as they cause significant gastrointestinal side effects 1
   • Contraindicated in patients with severe renal impairment (eGFR <30 mL/min) or concomitant use of strong P-glycoprotein/CYP3A4 inhibitors 2

2. NSAIDs:

   • All NSAIDs are equally effective for acute gout 3
   • Options include naproxen 500 mg twice daily for 5 days 1
   • Contraindicated in patients with renal disease, heart failure, or cirrhosis 3
   • Use with caution in patients with history of peptic ulcer disease (consider PPI co-therapy) 1

3. Corticosteroids:

   • Particularly useful when oral medications cannot be taken
   • Options include prednisone 30-35 mg daily for 3-5 days 1
   • Intra-articular injections effective for 1-2 large joints 1
   • Long-term use associated with dysphoria, mood disorders, elevated blood glucose, immune suppression, and fluid retention 3

Adjunctive Therapies

• Topical ice as an adjuvant treatment 1
• Rest of the affected joint 4
• Adequate hydration (at least 2 liters daily) 1

Chronic Gout Management

Indications for Urate-Lowering Therapy (ULT)

ULT should be initiated in patients with:

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

Urate-Lowering Medications

1. Allopurinol (First-line):

   • Starting dose: 100 mg daily (lower in renal insufficiency) 1, 5
   • Gradually increase dose at weekly intervals by 100 mg until target serum uric acid level of 6 mg/dL or less is attained 5
   • Maintenance dose: 200-300 mg/day for mild gout; 400-600 mg/day for moderately severe tophaceous gout 5
   • Maximum recommended dose: 800 mg daily 5
   • Dose adjustment required in renal impairment:
     • Creatinine clearance 10-20 mL/min: 200 mg daily
     • Creatinine clearance <10 mL/min: ≤100 mg daily 5

2. Febuxostat:

   • Alternative first-line when allopurinol is not tolerated or contraindicated 1
   • Equally effective as allopurinol at decreasing serum urate levels 3
   • Associated with abdominal pain, diarrhea, and musculoskeletal pain 3

3. Uricosuric drugs (e.g., probenecid):

   • Increase uric acid excretion 6
   • Consider for allopurinol-allergic patients with normal renal function and no history of urolithiasis 4

Prophylaxis During ULT Initiation

• Prophylactic therapy with low-dose colchicine or NSAIDs reduces risk of acute gout attacks when initiating ULT 3
• Continue prophylaxis for at least 6 months after achieving target uric acid levels 7
• High-quality evidence shows that continuing prophylaxis for more than 8 weeks is more effective than shorter durations 3

Monitoring and Follow-up

• Target serum uric acid levels below 6 mg/dL (360 μmol/L) 1
• Monitor serum uric acid levels to guide ULT dosing
• Ensure adequate fluid intake (at least 2 liters daily) and maintain neutral or slightly alkaline urine 5

Lifestyle Modifications

• Limit consumption of:
  • Alcohol (especially beer)
  • Purine-rich foods (organ meats, shellfish)
  • Beverages sweetened with high-fructose corn syrup 7
• Encourage consumption of:
  • Vegetables
  • Low-fat or nonfat dairy products 7
• Weight loss for overweight/obese patients 1
• Regular moderate physical activity 1

Common Pitfalls and Caveats

1. Initiating ULT during acute flares: Avoid starting ULT during an acute attack; wait until resolution of the flare 3

2. Inadequate prophylaxis: Failure to provide prophylaxis when initiating ULT can lead to increased flares in the first 6 months 3

3. Inappropriate colchicine use: High-dose colchicine regimens cause significant gastrointestinal side effects in nearly all patients 1

4. Medication interactions: Check for drug interactions, especially with colchicine and P-glycoprotein/CYP3A4 inhibitors 1, 2

5. Underdosing of ULT: Failure to titrate allopurinol to achieve target serum uric acid levels 5

6. Premature discontinuation of ULT: ULT should be continued long-term in patients with recurrent gout 3