What is the recommended management for gout?

Management of Gout

The recommended management for gout includes treating acute flares with low-dose colchicine, NSAIDs, or corticosteroids, followed by urate-lowering therapy (ULT) with allopurinol as first-line treatment, targeting serum uric acid levels <6 mg/dL, along with lifestyle modifications. 1, 2

Acute Gout Flare Management

First-line options (choose based on patient factors):

1. Oral colchicine

   • Most effective when started within 12 hours of symptom onset
   • Dosing: 1.2 mg initially, followed by 0.6 mg one hour later 2
   • Avoid in patients with severe renal impairment (CrCl <30 mL/min) 3
   • Contraindicated with strong P-glycoprotein/CYP3A4 inhibitors 2, 3

2. NSAIDs

   • Equally effective as corticosteroids for pain relief 2
   • Avoid in patients with history of peptic ulcer disease, GI bleeding, or cardiovascular disease 2
   • Associated with more gastrointestinal adverse events than corticosteroids 4

3. Corticosteroids (oral, intramuscular, or intra-articular)

   • Preferred in patients with contraindications to NSAIDs or colchicine
   • May provide faster pain relief than NSAIDs (3 vs 24 hours) 2
   • Safer GI profile than NSAIDs 4

Urate-Lowering Therapy (ULT)

Indications for ULT:

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

First-line ULT:

• Allopurinol
  • Start at 100 mg/day and increase by 100 mg increments every 2-4 weeks 1
  • Target serum uric acid <6 mg/dL (360 mmol/L) 1, 2
  • For severe gout (tophi, chronic arthropathy, frequent attacks), target <5 mg/dL (300 mmol/L) 1
  • Dose adjustment in renal impairment:
    • CrCl 10-20 mL/min: 200 mg/day
    • CrCl <10 mL/min: ≤100 mg/day 5

Alternative ULT options (if allopurinol is not tolerated or ineffective):

• Febuxostat

  • Equally effective as allopurinol at decreasing serum urate levels 2
  • No dose adjustment needed in mild to moderate renal impairment
  • Associated with abdominal pain, diarrhea, and musculoskeletal pain 2

• Uricosuric agents (e.g., probenecid)

  • Can be used alone or combined with allopurinol 1
  • Avoid in patients with history of nephrolithiasis or severe renal impairment 6

• Pegloticase

  • Reserved for severe, debilitating chronic tophaceous gout when other ULT options fail 1

Important ULT considerations:

1. Do not initiate ULT during an acute flare - wait until resolution 2
2. Provide prophylaxis when starting ULT to prevent flares:
   • Low-dose colchicine or NSAIDs
   • Continue for at least 3-6 months after reaching target uric acid level 2, 6
3. ULT should be lifelong 1
4. Monitor serum uric acid levels regularly 1

Lifestyle Modifications

• Weight loss for overweight/obese patients 2
• Dietary recommendations:
  • Avoid or limit alcohol (especially beer and spirits) 1, 2
  • Avoid sugar-sweetened drinks and foods rich in fructose 1, 2
  • Limit purine-rich foods (organ meats, shellfish) 7
  • Encourage low-fat dairy products 1, 2
  • Ensure adequate hydration (≥2 liters daily) 2, 5
• Regular moderate physical activity 2

Medication Adjustments

• Consider substituting diuretics if possible 1
• For hypertension, consider losartan (has uricosuric effect) 1, 2
• For hyperlipidemia, consider statins or fenofibrate 1

Common Pitfalls and Caveats

1. Failure to provide prophylaxis when starting ULT can lead to increased flares in the first 6 months 2
2. Inadequate ULT dosing - many patients require dose titration to reach target uric acid levels 1
3. Discontinuing ULT after symptom resolution - ULT should be maintained lifelong 1
4. Not adjusting allopurinol dose in renal impairment increases risk of severe hypersensitivity reactions 5
5. High-dose colchicine regimens cause significant gastrointestinal side effects in nearly all patients 2
6. Targeting serum uric acid <3 mg/dL is not recommended long-term 1

By following this comprehensive approach to gout management, focusing on both acute flare treatment and long-term urate-lowering therapy, patients can achieve better control of their disease and improved quality of life.