Treatment Plan for Gout
The optimal treatment plan for gout includes NSAIDs, colchicine, or corticosteroids for acute attacks, followed by long-term urate-lowering therapy with allopurinol or febuxostat to achieve serum urate levels below 6 mg/dL, along with prophylaxis during initiation of urate-lowering therapy. 1, 2
Management of Acute Gout Attacks
First-Line Options
- Treatment should be initiated within 24 hours of symptom onset for optimal outcomes 2
- NSAIDs at full anti-inflammatory doses are effective when started promptly 1
- Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is most effective when started within 12 hours of symptom onset 1, 2
- Oral prednisone (30-35 mg/day for 3-5 days or 0.5 mg/kg per day for 5-10 days) is recommended for patients with contraindications to NSAIDs or colchicine 1, 2
Special Considerations
- For polyarticular joint involvement, combination therapy may be appropriate 3
- Intra-articular corticosteroid injection is effective for 1-2 affected joints 2
- Topical ice application is recommended as an adjunctive measure during acute attacks 2
- Established urate-lowering therapy should be continued without interruption during acute attacks 2
Medication Adjustments
- Colchicine requires dose adjustment in patients with renal impairment 4
- NSAIDs should be avoided in patients with renal disease, heart failure, or cirrhosis 1
- For patients with severe renal impairment, corticosteroids are preferred as they do not worsen renal function 5
Long-Term Management
Urate-Lowering Therapy (ULT)
- Initiate ULT after multiple attacks or after development of tophi or urate nephrolithiasis 1
- Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options 1, 2
- Allopurinol starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 1
- Target serum urate level should be below 6 mg/dL (357 μmol/L) 1, 2
- ULT can be safely initiated during an acute gout attack without prolonging the attack 6
Prophylaxis During ULT Initiation
- Anti-inflammatory prophylaxis should be initiated with or just before starting ULT 1, 2
- Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) is recommended as first-line prophylaxis 1, 2
- NSAIDs at low doses with gastroprotection are an alternative option 2
- Prophylaxis should be continued for the greater of six months duration or three months after achieving target serum urate for patients without tophi 3, 1
- For patients with tophi, prophylaxis should continue for six months after achieving target serum urate and resolution of tophi 3, 1
Lifestyle Modifications
- Weight loss is recommended for obese patients 1, 2
- Avoid alcohol (especially beer and spirits) and sugar-sweetened drinks 1
- Limit consumption of purine-rich foods (e.g., organ meats, shellfish) 7
- Encourage consumption of vegetables and low-fat or nonfat dairy products 7
Common Pitfalls to Avoid
- Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 2
- Using high-dose colchicine regimens causes significant gastrointestinal side effects, while low-dose regimens are equally effective with fewer adverse events 2
- Discontinuing ULT during acute attacks can worsen outcomes 2
- Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 2
- Using standard doses of medications in patients with renal impairment without appropriate adjustments 4
Treatment Algorithm
Acute Attack Management:
After Resolution of Acute Attack:
Long-term Management: