What is the recommended treatment for gout?

Treatment of Gout

The recommended treatment for gout includes NSAIDs, colchicine, or corticosteroids for acute attacks, and urate-lowering therapy (ULT) with allopurinol as first-line treatment for long-term management in patients with recurrent attacks, tophi, or radiographic changes. 1

Acute Gout Attack Management

• Acute gouty arthritis attacks should be treated with pharmacologic therapy initiated within 24 hours of symptom onset for optimal outcomes 1
• First-line options for mild to moderate attacks (affecting 1-3 small joints or 1-2 large joints) include:
  • NSAIDs at full anti-inflammatory doses 1
  • Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) - most effective when started within 12-36 hours of symptom onset 1, 2, 3
  • Corticosteroids (oral, intra-articular, or intramuscular) 1
• For severe or polyarticular attacks, combination therapy may be appropriate 1
• Ongoing urate-lowering therapy should not be interrupted during an acute attack 1
• Choice of medication should consider patient comorbidities:
  • NSAIDs should be avoided in patients with renal disease, heart failure, or cirrhosis 2
  • Colchicine requires dose adjustment in patients with renal impairment 3

Long-Term Management

• Urate-lowering therapy (ULT) is indicated for patients with: 1

  • Recurrent acute attacks
  • Tophi
  • Gouty arthropathy
  • Radiographic changes of gout
  • Uric acid nephrolithiasis

• Allopurinol is strongly recommended as the preferred first-line ULT agent due to its efficacy, safety, and lower cost 1, 2

  • Start at low dose (≤100 mg/day, lower in CKD) with gradual upward titration 1, 2
  • Can be used in patients with mild-moderate renal impairment with close monitoring 1

• Alternative ULT options if allopurinol is not tolerated or ineffective: 1

  • Febuxostat
  • Uricosurics (probenecid, benzbromarone)
  • Combination therapy (xanthine oxidase inhibitor with uricosuric)
  • Pegloticase for refractory cases

• The therapeutic target is to maintain serum uric acid below 6 mg/dL (360 μmol/L), or below 5 mg/dL (300 μmol/L) in severe cases with tophi 1

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis should be initiated when starting ULT to prevent acute flares 1, 2
• Recommended prophylactic options include:
  • Colchicine 0.5-1.0 mg daily (with dose adjustment for renal impairment) 1, 2, 3
  • Low-dose NSAIDs (with gastroprotection if indicated) 1
  • Low-dose corticosteroids if colchicine and NSAIDs are contraindicated 2
• Prophylaxis should continue for at least 3-6 months, or longer if there is ongoing disease activity or target urate levels have not been achieved 2, 4

Lifestyle Modifications

• Patient education about dietary and lifestyle modifications is essential 1
• Recommended lifestyle changes include:
  • Weight loss if obese 1, 2
  • Reduced alcohol consumption, especially beer 1, 2
  • Limited intake of purine-rich foods (organ meats, shellfish) 4
  • Avoidance of beverages sweetened with high-fructose corn syrup 2, 4
  • Regular exercise 1, 2
  • Adequate hydration 4

Special Considerations

• In patients taking diuretics that contribute to hyperuricemia, consider discontinuing the diuretic if possible 1
• Patients with renal impairment require careful dose adjustment of medications:
  • Allopurinol should be started at lower doses (50-100 mg/day) 1, 3
  • Colchicine requires reduced dosing in moderate-severe renal impairment 3
• Elderly patients may require more cautious dosing due to higher likelihood of comorbidities and decreased renal function 3

Common Pitfalls to Avoid

• Failure to initiate treatment of acute attacks within 24 hours 1
• Interrupting ULT during an acute attack, which can worsen and prolong the flare 1
• Starting ULT without prophylaxis, leading to increased risk of acute attacks 1, 2
• Inadequate ULT dosing - allopurinol often requires doses >300 mg/day to reach target urate levels 1
• Treating asymptomatic hyperuricemia without clinical gout is not recommended 1
• Using high-dose colchicine for acute attacks, which increases toxicity without improving efficacy 3, 5