What are the treatment options for managing gout?

Treatment Options for Gout

The management of gout requires a dual approach focusing on treating acute flares with anti-inflammatory medications and preventing recurrent attacks through urate-lowering therapy (ULT) and lifestyle modifications. 1

Acute Gout Flare Management

• Acute flares should be treated as early as possible, ideally within 24 hours of symptom onset for optimal outcomes 2, 1

• Patients should be educated to self-medicate at the first warning symptoms ("pill in the pocket" approach) 2

• First-line treatment options include:

  • Colchicine: 1 mg loading dose followed by 0.5 mg one hour later (within 12 hours of flare onset) 2, 3
  • NSAIDs at full anti-inflammatory doses (plus proton pump inhibitor if appropriate) 2, 1
  • Oral corticosteroids (30-35 mg/day of equivalent prednisolone for 3-5 days) 2, 1
  • Articular aspiration and injection of corticosteroids (particularly effective for 1-2 affected joints) 2, 1

• For severe flares involving multiple joints, combination therapy may be considered (e.g., colchicine plus NSAID or colchicine plus corticosteroid) 2

• In patients with contraindications to standard therapies:

  • IL-1 blockers should be considered for treating flares in patients with frequent attacks and contraindications to colchicine, NSAIDs, and corticosteroids 2
  • Current infection is a contraindication to IL-1 blockers 2

Important Considerations for Acute Treatment

• Colchicine and NSAIDs should be avoided in patients with severe renal impairment 2, 3
• Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors (e.g., cyclosporin, clarithromycin) 2, 3
• For patients with renal impairment requiring colchicine, dose adjustments are necessary 3
• Topical ice application is recommended as an adjunctive measure during acute attacks 1

Long-term Management and Prevention

Urate-Lowering Therapy (ULT)

• ULT should be considered and discussed with every patient with a definite diagnosis of gout from the first presentation 2

• ULT is indicated in patients with:

  • Recurrent flares
  • Tophi
  • Urate arthropathy
  • Renal stones 2, 1

• The target serum urate level should be below 6 mg/dL 1, 4

• First-line ULT options:

  • Xanthine oxidase inhibitors (allopurinol, febuxostat) 1, 4

Prophylaxis During ULT Initiation

• Prophylaxis against flares should be provided during the first 6 months of ULT 2, 1
• Recommended prophylactic options:
  • Colchicine: 0.5-1 mg/day (dose should be reduced in patients with renal impairment) 2, 3
  • Low-dose NSAIDs with gastroprotection if colchicine is not tolerated or contraindicated 2
• Duration of prophylaxis:
  • 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

Lifestyle Modifications

• Weight loss if appropriate 2, 1
• Avoidance of alcohol (especially beer and spirits) 2, 1
• Avoidance of sugar-sweetened drinks and high-fructose corn syrup 2, 1
• Limitation of heavy meals and excessive intake of meat and seafood 2
• Encouragement of low-fat dairy products 2
• Regular exercise 2

Special Populations

Renal Impairment

• For acute gout flares in severe renal impairment:

  • Treatment course should not be repeated more than once every two weeks 3
  • For patients on dialysis, colchicine dose should be reduced to a single dose of 0.6 mg 3

• For ULT prophylaxis in renal impairment:

  • Patients with severe renal failure should start colchicine at 0.3 mg/day 3
  • Patients undergoing dialysis should take colchicine 0.3 mg twice weekly 3

Hepatic Impairment

• Patients with severe hepatic impairment:
  • For acute flares, treatment course should not be repeated more than once every two weeks 3
  • For prophylaxis, dose reduction should be considered 3

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1
• Using high-dose colchicine regimens causes significant gastrointestinal side effects 1
• Discontinuing ULT during acute attacks can worsen outcomes; established ULT should be continued during attacks 1
• Failing to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 1
• Neglecting to screen for and manage comorbidities (renal impairment, cardiovascular disease, diabetes) 2