What is the management approach for gouty arthritis?

Management of Gouty Arthritis

The management of gouty arthritis requires prompt treatment of acute attacks with NSAIDs, colchicine, or corticosteroids initiated within 24 hours of symptom onset, followed by urate-lowering therapy with prophylaxis to prevent recurrent flares. 1, 2

Acute Gout Management

First-Line Treatment Options

• Initiate pharmacologic therapy within 24 hours of acute gout attack onset for optimal outcomes 3, 1
• Continue ongoing urate-lowering therapy without interruption during an acute attack 3, 1
• First-line options include:
  • NSAIDs at full FDA-approved anti-inflammatory doses (naproxen, indomethacin, sulindac) 3, 2
  • Oral colchicine (1.2 mg followed by 0.6 mg one hour later, then prophylactic dosing) 3, 2
  • Corticosteroids:
    • Oral prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or
    • 2-5 days at full dose followed by 7-10 day taper 3, 2
    • Intra-articular injection for single joint involvement 3
    • Intramuscular triamcinolone acetonide 60 mg 3

Treatment Based on Joint Involvement and Pain Severity

• For mild to moderate pain with limited joint involvement:
  • Monotherapy with any first-line agent is appropriate 2
• For severe pain or polyarticular involvement:
  • Combination therapy is recommended 3, 1
  • Acceptable combinations include:
    • Colchicine plus NSAIDs
    • Oral corticosteroids plus colchicine
    • Intra-articular steroids with any other modality 3
  • Avoid combining NSAIDs with systemic corticosteroids due to increased GI toxicity risk 3, 1

Long-Term Management

Urate-Lowering Therapy (ULT)

• Allopurinol is the first-line medication for prevention of recurrent gout 4, 5
  • Start with 100 mg daily and increase by 100 mg weekly
  • Target serum uric acid level of 6 mg/dL or less
  • Adjust dose based on renal function:
    • For creatinine clearance 10-20 mL/min: maximum 200 mg daily
    • For creatinine clearance <10 mL/min: maximum 100 mg daily 4

Anti-inflammatory Prophylaxis

• Initiate prophylaxis with or just prior to starting ULT 3, 1
• First-line prophylaxis options:
  • Low-dose colchicine (0.6 mg once or twice daily) 3, 1
  • Low-dose NSAIDs with proton pump inhibitor where indicated 3
• Second-line option:
  • Low-dose prednisone or prednisolone (<10 mg/day) if colchicine and NSAIDs are not tolerated, contraindicated, or ineffective 3
• Duration of prophylaxis:
  • At least 6 months, or
  • 3 months after achieving target serum urate if no tophi are detected on physical exam, or
  • 6 months after achieving target serum urate if tophi are present 3, 1

Special Considerations

Renal Impairment

• Corticosteroids are generally safer than NSAIDs or colchicine 2
• Allopurinol dosing must be adjusted based on creatinine clearance 4
• Monitor renal function during early stages of allopurinol therapy 4

Elderly Patients

• More cautious with NSAID use due to increased risk of adverse effects 6
• Consider corticosteroids as first-line therapy in patients with contraindications to NSAIDs 6
• Start allopurinol at lower doses (50-100 mg) and titrate slowly 6

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1
• Stopping urate-lowering therapy during an acute attack can worsen and prolong the attack 1
• Failing to provide prophylaxis when initiating urate-lowering therapy 1
• Inadequate dose titration of allopurinol leading to suboptimal serum urate levels 7
• Not continuing prophylaxis for the recommended duration 3, 1