What are the treatment options for gout?

Treatment Options for Gout

The treatment of gout should follow a two-pronged approach: managing acute attacks with anti-inflammatory medications initiated within 24 hours of symptom onset, and implementing long-term urate-lowering therapy for patients with recurrent attacks, tophi, or chronic gouty arthropathy. 1

Management of Acute Gout Attacks

• Pharmacologic therapy should be initiated within 24 hours of symptom onset for optimal outcomes 1
• For attacks involving 1-3 small joints or 1-2 large joints, monotherapy with NSAIDs at full anti-inflammatory doses is appropriate 1
• Low-dose oral colchicine (1.2 mg followed by 0.6 mg one hour later) is effective with fewer gastrointestinal side effects compared to high-dose regimens 1, 2
• Oral prednisone (0.5 mg/kg per day for 5-10 days) is an effective alternative when NSAIDs or colchicine are contraindicated 1, 3
• Intra-articular corticosteroid injection is recommended for 1-2 affected joints 1
• For severe polyarticular attacks, combination therapy may be appropriate (colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality) 3
• Topical ice application is recommended as an adjunctive measure during acute attacks 1
• Continue established urate-lowering therapy without interruption during acute attacks 1, 4

Special Considerations for Acute Treatment

• In patients with renal impairment, colchicine dosing requires adjustment - for severe impairment, treatment course should not be repeated more than once every two weeks 2
• For patients undergoing dialysis, the total recommended dose for gout flares should be reduced to a single dose of 0.6 mg 2
• In patients with severe hepatic impairment, treatment course with colchicine should not be repeated more than once every two weeks 2

Long-term Management of Chronic Gout

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

  • Recurrent acute attacks
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout 1

• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options for urate-lowering therapy 1, 5

• The target serum urate level should be below 6 mg/dL 1

• When initiating allopurinol:

  • Start with no more than 100 mg/day for any patient
  • Start with 50 mg/day in patients with chronic kidney disease stage 4 or worse
  • Gradually increase dose every 2-5 weeks until reaching target uric acid level 4, 5

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis is recommended whenever ULT is initiated 1, 4
• First-line prophylactic options include:
  • Low-dose colchicine (0.5-0.6 mg once or twice daily, adjusted for renal function) 1, 3
  • Low-dose NSAIDs with gastroprotection if indicated 1
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 3
• Prophylaxis duration should be continued for:
  • At least 6 months, or
  • 3 months after achieving target serum urate for patients without tophi, or
  • 6 months after achieving target serum urate where tophi have resolved 1, 3

Non-Pharmacologic Measures

• Weight loss is recommended for obese patients 1, 4
• Avoid alcoholic drinks, especially beer 1
• Avoid beverages sweetened with high-fructose corn syrup 1, 5
• Limit consumption of purine-rich foods (organ meats, shellfish) 5
• Encourage consumption of vegetables and low-fat or nonfat dairy products 5

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1
• High-dose colchicine regimens cause significant gastrointestinal side effects 1, 2
• Discontinuing ULT during acute attacks can worsen outcomes 1, 4
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 1
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 6
• Loop and thiazide diuretics can increase uric acid levels 5
• The angiotensin receptor blocker losartan increases urinary excretion of uric acid and may be beneficial in patients requiring antihypertensive therapy 5