Treatment Options for Gout
The first-line treatments for acute gout flares are NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), with treatment initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3
Acute Gout Attack Management
- Colchicine is most effective when started within 12 hours of symptom onset using the low-dose regimen (1.2 mg followed by 0.6 mg one hour later) 1, 3
- NSAIDs at full anti-inflammatory doses (e.g., naproxen 500 mg twice daily) are effective when started promptly 1, 2
- Oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days) are recommended for patients with contraindications to NSAIDs or colchicine 1, 3
- Intra-articular corticosteroid injection is an effective option for single joint involvement 1, 2
- For severe attacks involving multiple joints, combination therapy (e.g., colchicine with NSAIDs or colchicine with corticosteroids) can be considered 3
- Topical ice application is recommended as an adjunctive measure during acute attacks 2
Special Considerations for Acute Treatment
- Colchicine should be avoided in patients with severe renal impairment (GFR < 30 mL/min) 3, 4
- In patients with severe renal impairment requiring colchicine, treatment courses should not be repeated more than once every two weeks 4
- For patients undergoing dialysis, the total recommended dose for gout flares should be reduced to a single dose of 0.6 mg 4
- Patients with severe hepatic impairment should not repeat colchicine treatment courses more than once every two weeks 4
Long-Term Management and Prevention
- Xanthine oxidase inhibitors (allopurinol or febuxostat) are recommended as first-line options for long-term management of gout 1, 2, 5
- Uricosuric agents (probenecid, benzbromarone) can be used as alternatives in patients with normal renal function 1, 5
- The target serum urate level should be below 6 mg/dL 2, 5
- Anti-inflammatory prophylaxis is strongly recommended when starting urate-lowering therapy to prevent flares, with options including: 1, 2
- Low-dose colchicine (0.5-0.6 mg once or twice daily)
- Low-dose NSAIDs with gastroprotection if indicated
- Low-dose prednisone
- Prophylaxis should continue for at least 6 months, or 3 months after achieving target serum urate if no tophi are present, or 6 months after achieving target serum urate if tophi are present 1, 2, 5
Lifestyle Modifications
- Weight loss is recommended for obese patients 1, 2
- Avoid alcoholic drinks, especially beer 2, 5
- Avoid beverages sweetened with high-fructose corn syrup 2, 5
- Limit consumption of purine-rich foods (e.g., organ meats, shellfish) 5
- Encourage consumption of vegetables and low-fat or nonfat dairy products 5
Common Pitfalls and Caveats
- Failing to start treatment early (within 24 hours) significantly reduces effectiveness 1, 2, 3
- High-dose colchicine regimens cause significant gastrointestinal side effects, while low-dose regimens are equally effective with fewer adverse events 2, 3
- Discontinuing urate-lowering therapy during acute flares should be avoided; continuing established therapy is now recommended 1, 2, 3
- Inadequate duration of prophylaxis when initiating urate-lowering therapy often leads to breakthrough flares and poor medication adherence 1, 2
- NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 2
- Drug interactions with colchicine should be carefully monitored, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 3