What are the treatment options for gout?

Treatment Options for Gout

For acute gout attacks, first-line treatment options include corticosteroids, NSAIDs, or colchicine, with the choice based on patient factors, comorbidities, and timing of intervention. 1

Acute Gout Attack Management

First-Line Treatment Options

• Colchicine is most effective when started within 12 hours of symptom onset, using a low-dose regimen of 1.2 mg followed by 0.6 mg one hour later 1
• NSAIDs at full anti-inflammatory doses (e.g., naproxen 500 mg twice daily) are effective when started promptly 1
• Oral corticosteroids (e.g., prednisolone 30-35 mg daily for 3-5 days) are particularly appropriate for patients with contraindications to NSAIDs or colchicine 1
• For single joint involvement, intra-articular corticosteroid injection is an effective option 1

Special Considerations

• Low-dose colchicine is strongly recommended over high-dose colchicine due to similar efficacy but fewer side effects 1, 2
• Patients with renal impairment require dose adjustments for colchicine; in severe renal impairment, treatment courses should not be repeated more than once every two weeks 2
• For patients unable to take oral medications, parenteral glucocorticoids are strongly recommended 1
• Topical ice can be used as an adjunctive treatment for acute flares 1

Combination Therapy

• For severe acute gout attacks with multiple joint involvement, combination therapy may be appropriate, including:
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with other modalities 1

Long-Term Management and Prevention

Urate-Lowering Therapy (ULT)

• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line for long-term management 1, 3
• Uricosuric agents (probenecid, benzbromarone) can be used as alternatives in patients with normal renal function 1, 4
• Target serum urate level should be below 6 mg/dL (360 μmol/L) 3

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis is strongly recommended when starting ULT to prevent flares 1
• First-line prophylaxis options include:
  • Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) 1
  • Low-dose NSAIDs with gastroprotection if indicated 1
• Second-line option: Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1

Duration of Prophylaxis

• Continue prophylaxis for at least 6 months, or 1
• 3 months after achieving target serum urate if no tophi are present 1
• 6 months after achieving target serum urate if tophi are present 1

Lifestyle Modifications

• Limit consumption of purine-rich foods (organ meats, shellfish) 3
• Avoid alcoholic beverages, especially beer 3
• Avoid beverages sweetened with high-fructose corn syrup 3
• Encourage consumption of vegetables and low-fat dairy products 3
• Weight loss if obese 1

Common Pitfalls and Caveats

• Failing to start treatment early - acute gout should be treated as soon as possible for best results 1
• Using high-dose colchicine regimens - low-dose is equally effective with fewer side effects 1, 5
• Not adjusting colchicine dosing in patients with renal impairment or those taking P-glycoprotein/CYP3A4 inhibitors 2
• Discontinuing ULT during acute flares - this practice should be avoided 1
• Inadequate duration of prophylaxis when initiating ULT, leading to breakthrough flares 1
• Not considering drug interactions, particularly with colchicine which can lead to serious toxicity 1, 2

The evidence strongly supports early intervention with appropriate anti-inflammatory therapy for acute attacks, followed by lifestyle modifications and, when indicated, long-term ULT with proper prophylaxis to prevent recurrent flares and complications of chronic gout.