What is the diagnosis and treatment for Gout (Gouty Arthritis)?

From the Guidelines

Gout should be managed with a treat-to-target approach, using urate-lowering therapy (ULT) such as allopurinol as the preferred first-line treatment, with a target serum urate level of <6 mg/dl, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The diagnosis of gout is typically made based on clinical presentation, laboratory tests, and imaging studies.

• Clinical presentation: sudden onset of intense pain, swelling, and redness in the affected joint, most commonly the big toe.
• Laboratory tests: elevated serum urate levels, although not always present during an acute attack.
• Imaging studies: X-rays, ultrasound, or dual-energy computed tomography (DECT) to detect urate crystals and joint damage.

For acute gout attacks, treatment options include:

• Colchicine (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve) 1.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days.
• Glucocorticoids like prednisone (30-40mg daily, tapered over 7-10 days).

For long-term management, lifestyle modifications are crucial, including:

• Limiting alcohol and purine-rich foods (red meat, seafood, organ meats).
• Maintaining a healthy weight.
• Staying hydrated. Medications for preventing future attacks include:
• Allopurinol (starting at 100mg daily, gradually increasing to 300-600mg daily) or febuxostat (40-80mg daily), which lower uric acid production 1.
• Probenecid (250mg twice daily, increasing to 500mg twice daily), which increases uric acid excretion. During the first 3-6 months of urate-lowering therapy, prophylactic low-dose colchicine (0.6mg daily) or NSAIDs may be prescribed to prevent flares, as recommended by the 2020 American College of Rheumatology guideline 1. Regular monitoring of uric acid levels is essential, with a target below 6mg/dL to prevent crystal formation and recurrent attacks.

From the FDA Drug Label

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. Treatment of gout flares with Colchicine Tablets, USP is not recommended in patients receiving prophylactic dose of Colchicine Tablets, USP and CYP3A4 inhibitors.

The diagnosis of Gout (Gouty Arthritis) is not explicitly stated in the provided drug labels. The treatment for Gout (Gouty Arthritis) includes:

• Indomethacin: effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis.
• Colchicine: for prophylaxis of gout flares, with dose adjustments recommended for patients with renal impairment. Key considerations for treatment include:
• Renal function: patients with renal impairment may require dose adjustments.
• Hepatic function: patients with hepatic impairment may require dose adjustments.
• Concomitant medications: patients receiving certain medications, such as CYP3A4 inhibitors, may require alternative treatments. 2 3

From the Research

Diagnosis of Gout

• Gout is characterized by painful joint inflammation, most commonly in the first metatarsophalangeal joint, resulting from precipitation of monosodium urate crystals in a joint space 4
• Gout is typically diagnosed using clinical criteria from the American College of Rheumatology 4
• Diagnosis may be confirmed by identification of monosodium urate crystals in synovial fluid of the affected joint 4

Treatment of Acute Gout

• Acute gout may be treated with nonsteroidal anti-inflammatory drugs, corticosteroids, or colchicine 4, 5, 6
• Colchicine has been widely used but toxicity, especially gastrointestinal adverse effects, are a major concern 5
• NSAIDs are the most widely prescribed drugs in the treatment of acute gout, but comorbidities should always be kept in mind when prescribing NSAIDs 5
• Corticosteroids are probably a reasonable choice for patients in whom colchicine and NSAIDs may be hazardous or for those with a history of previous intolerance to these drugs 5

Prevention of Recurrent Gout

• To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods and avoid alcoholic drinks and beverages sweetened with high-fructose corn syrup 4
• Consumption of vegetables and low-fat or nonfat dairy products should be encouraged 4
• Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 4, 7, 6, 8
• Uricosuric agents, such as probenecid, increase uric acid excretion and may be used as adjuncts 6, 8

Urate-Lowering Therapy

• The goal of urate-lowering therapy is to reduce serum uric acid levels to below 360 µmol/l ("treat to target") 7, 8
• Allopurinol and febuxostat are xanthine oxidase inhibitors that are effective in reducing uric acid levels 7, 6, 8
• The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid 4