What are the treatment options for gout?

Treatment Options for Gout

The first-line treatments for acute gout attacks include NSAIDs, oral colchicine, or corticosteroids, with treatment selection based on comorbidities and timing since symptom onset. 1, 2, 3

Management of Acute Gout Attacks

Initial Treatment Approach

• Pharmacologic therapy should be initiated within 24 hours of symptom onset for optimal outcomes 1, 2
• Continue established urate-lowering therapy without interruption during acute attacks 1, 2
• Patient education should include instructions for self-initiation of treatment upon first signs of an acute attack 1

First-line Treatment Options for Mild/Moderate Attacks

• For attacks involving 1-3 small joints or 1-2 large joints, monotherapy is appropriate: 1
  • NSAIDs at full anti-inflammatory doses 1
  • Oral colchicine at low dose (1.2 mg followed by 0.6 mg one hour later) 1, 2, 4
  • Oral prednisone (0.5 mg/kg per day for 5-10 days) 1, 3
  • Intra-articular corticosteroid injection for 1-2 affected joints 1, 3

Treatment for Severe/Polyarticular Attacks

• Combination therapy is recommended for severe pain or polyarticular attacks 1, 5
• Effective combination approaches include: 5
  • Colchicine plus NSAIDs 5
  • Oral corticosteroids plus colchicine 5
  • Intra-articular steroids with any other modality 5

Special Considerations for NPO Patients

• Intra-articular corticosteroid injection for 1-2 affected joints 1
• Intravenous/intramuscular methylprednisolone (0.5-2.0 mg/kg) 1, 5
• Subcutaneous ACTH (25-40 IU initially) with repeat doses as needed 1

Long-term Management of Chronic Gout

Indications for Urate-Lowering Therapy (ULT)

• ULT is indicated for patients with: 1, 3
  • Recurrent acute attacks 2, 3
  • Tophi 3
  • Chronic gouty arthropathy 3
  • Radiographic changes of gout 1

Urate-Lowering Medication Options

• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options 3, 6
• Allopurinol starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 3
• Uricosuric drugs (probenecid, benzbromarone) can be used when xanthine oxidase inhibitors are contraindicated 1, 6
• Target serum urate level should be below 6 mg/dL 3

Prophylaxis During Urate-Lowering Therapy

Prophylactic Medications

• Anti-inflammatory prophylaxis is recommended whenever ULT is initiated 1, 2, 3
• First-line prophylactic options include: 1
  • Low-dose colchicine (0.5-0.6 mg once or twice daily, adjusted for renal function) 1, 2, 3
  • Low-dose NSAIDs with gastroprotection if indicated 1, 3
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 5, 3

Duration of Prophylaxis

• Continue prophylaxis for the greater of: 1, 3
  • Six months duration, or 1, 3
  • Three months after achieving target serum urate for patients without tophi, or 1, 3
  • Six months after achieving target serum urate where tophi have resolved 1

Medication Adjustments for Special Populations

Renal Impairment

• For colchicine in severe renal impairment, treatment course should not be repeated more than once every two weeks 4
• For patients on dialysis, colchicine dose should be reduced to 0.6 mg as a single dose 4
• NSAIDs should be avoided in patients with significant renal disease 3

Hepatic Impairment

• For severe hepatic impairment, colchicine treatment course should not be repeated more than once every two weeks 4
• Dose reduction should be considered for prophylaxis in patients with severe hepatic impairment 4

Non-Pharmacologic Measures

• Topical ice application is recommended as an adjunctive measure during acute attacks 1
• Weight loss is recommended for obese patients 3
• Limit consumption of purine-rich foods (organ meats, shellfish) 7
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 3, 7
• Encourage consumption of vegetables and low-fat dairy products 7

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1, 2
• High-dose colchicine regimens cause significant gastrointestinal side effects; low-dose regimens are equally effective with fewer adverse events 1, 2
• Discontinuing ULT during acute attacks can worsen outcomes; continue established ULT during attacks 1, 2
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 1, 3
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 3