What are the treatment options for gout?

Treatment Options for Gout

For acute gout attacks, first-line treatments include corticosteroids, NSAIDs, or low-dose colchicine, which should be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3

Acute Gout Attack Management

• Pharmacologic therapy should be initiated within 24 hours of symptom onset for optimal effectiveness 3
• NSAIDs at full anti-inflammatory doses (e.g., naproxen 500 mg twice daily) are effective when started promptly 2, 3
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is recommended, particularly when started within 12 hours of symptom onset 2, 3
• Oral corticosteroids (e.g., prednisolone 30-35 mg daily for 3-5 days or prednisone 0.5 mg/kg per day for 5-10 days) are recommended, especially for patients with contraindications to NSAIDs or colchicine 2, 3
• Intra-articular corticosteroid injection is effective for single joint involvement 2, 3
• Topical ice application is recommended as an adjunctive measure during acute attacks 3

Important Considerations for Acute Treatment

• The most important determinant of therapeutic success is how soon therapy is initiated 4
• Continuing established urate-lowering therapy without interruption during acute attacks is recommended 3
• For patients with renal impairment receiving colchicine:
  • No dose adjustment needed for mild to moderate renal impairment 5
  • For severe renal impairment, treatment course should not be repeated more than once every two weeks 5
  • For patients on dialysis, reduce to a single dose of 0.6 mg 5

Long-term Management of Chronic Gout

• The American College of Physicians (ACP) recommends against initiating urate-lowering therapy after a first gout attack or in patients with infrequent attacks 1

• Urate-lowering therapy is indicated for patients with:

  • Recurrent acute attacks
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout 3

• When urate-lowering therapy is appropriate, options include:

  • Xanthine oxidase inhibitors (allopurinol, febuxostat) as first-line options 2, 3
  • Uricosuric agents (probenecid, benzbromarone) as alternatives in patients with normal renal function and no history of urolithiasis 2
  • Pegloticase for chronic gout refractory to conventional therapy 6

• Target serum urate level should be below 6 mg/dL 3

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis is strongly recommended when starting urate-lowering therapy to prevent flares 2, 3

• Prophylactic options include:

  • Low-dose colchicine (0.5-0.6 mg once or twice daily)
  • Low-dose NSAIDs with gastroprotection if indicated
  • Low-dose prednisone 2, 3

• Prophylaxis duration should be 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 2, 3, 7

Non-Pharmacologic Measures

• Weight loss is recommended for obese patients 2, 3
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 3, 7
• 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 and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 3
• High-dose colchicine regimens cause significant gastrointestinal side effects, while low-dose regimens are equally effective with fewer adverse events 3
• Discontinuing urate-lowering therapy during acute flares should be avoided 2, 3
• Inadequate duration of prophylaxis when initiating urate-lowering therapy can lead to breakthrough flares and poor medication adherence 2, 3
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 3
• Drug interactions, particularly with colchicine, should be considered to avoid serious toxicity 2
• Monitoring serum uric acid levels prior to each pegloticase infusion is crucial, with discontinuation if levels increase to above 6 mg/dL, particularly when 2 consecutive levels above 6 mg/dL are observed 6