What are the guidelines for treating gout?

Guidelines for Treating Gout

For gout management, first-line treatment for acute attacks includes corticosteroids, NSAIDs, or colchicine, while long-term management requires urate-lowering therapy with xanthine oxidase inhibitors like allopurinol or febuxostat, along with prophylaxis during initiation. 1

Acute Gout Attack Management

First-Line Treatment Options

• Corticosteroids should be considered as first-line therapy in patients without contraindications due to their safety profile and cost-effectiveness 1
• NSAIDs at full anti-inflammatory doses are effective when started promptly 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is most effective when started within 12 hours of symptom onset 1, 2

Specific Medication Recommendations

• Oral prednisone: 30-35 mg/day for 3-5 days or 0.5 mg/kg per day for 5-10 days 1, 3
• Intra-articular corticosteroid injection for single or limited joint involvement 1, 2
• Colchicine dosing should be adjusted for renal impairment to avoid toxicity 4
• NSAIDs should be avoided in patients with renal disease, heart failure, or cirrhosis 1

Treatment Selection Considerations

• Choice of therapy should be based on:

  • Presence of contraindications
  • Time since symptom onset (colchicine most effective within 12 hours)
  • Number and type of joints involved
  • Patient's previous response to treatments 1, 2

• For severe polyarticular attacks, combination therapy may be appropriate:

  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality 3

Long-Term Management

Urate-Lowering Therapy (ULT)

• Initiate ULT after multiple attacks or after development of tophi or urate nephrolithiasis 1

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options 1, 2

• Allopurinol recommendations:

  • Starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 1
  • Gradually titrate dose upward every 2-5 weeks to achieve target serum urate level 1, 5
  • Dose can exceed 300 mg daily even with renal impairment, with appropriate monitoring 1, 5
  • Consider HLA-B*5801 testing in high-risk populations (Koreans with CKD, Han Chinese, Thai) 1

• Uricosuric agents (e.g., probenecid) are alternatives when:

  • Patient is allergic to allopurinol
  • Patient has normal renal function
  • No history of urolithiasis 1

Target Serum Urate Levels

• Treat to target serum urate level below 6 mg/dL (357 μmol/L) 1, 6
• Continue ULT without interruption during acute attacks 3

Prophylaxis During ULT Initiation

Prophylactic Therapy

• Anti-inflammatory prophylaxis should be initiated with or just before starting ULT 1, 2
• Options include:
  • Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) as first-line 1, 2
  • Low-dose NSAIDs with PPI if appropriate 1
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1, 3

Duration of Prophylaxis

• Continue prophylaxis for the greater of:
  • Six months duration, or
  • Three months after achieving target serum urate for patients without tophi, or
  • Six months after achieving target serum urate for patients with tophi 1, 2

Lifestyle Modifications

• Weight loss for obese patients 2
• Avoid alcohol (especially beer and spirits) and sugar-sweetened drinks 1
• Limit intake of purine-rich foods (organ meats, shellfish) 7
• Encourage consumption of vegetables and low-fat dairy products 7

Common Pitfalls and Caveats

• Failing to start treatment early can lead to poor outcomes 2
• Discontinuing ULT during acute flares should be avoided 3, 2
• Inadequate duration of prophylaxis when initiating ULT can lead to breakthrough flares 2
• Drug interactions with colchicine must be considered to avoid serious toxicity 4
• Monitoring for allopurinol hypersensitivity reactions, particularly in high-risk populations 1