What are the treatment options for gout?

Treatment Options for Gout

For optimal outcomes in gout management, pharmacologic therapy should be initiated within 24 hours of symptom onset, with treatment options including NSAIDs, colchicine, or corticosteroids for acute attacks, and xanthine oxidase inhibitors as first-line therapy for long-term management. 1, 2, 3

Management of Acute Gout Attacks

• Treatment should be initiated within 24 hours of symptom onset for optimal effectiveness 1, 3
• For attacks involving 1-3 small joints or 1-2 large joints, monotherapy with one of the following is appropriate:
  • NSAIDs at full anti-inflammatory doses 1, 3
  • Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) - most effective when started within 12 hours of symptom onset 1, 2
  • Oral prednisone (0.5 mg/kg per day for 5-10 days or 30-35 mg/day for 3-5 days) 1, 2
  • Intra-articular corticosteroid injection for 1-2 affected joints 1, 3
• For polyarticular or severe attacks, combination therapy may be appropriate 2
• Topical ice application is recommended as an adjunctive measure during acute attacks 1, 3
• Continue established urate-lowering therapy without interruption during acute attacks 1, 3

Special Considerations for Acute Treatment

• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 3
• For patients with renal impairment receiving colchicine:
  • Mild to moderate impairment: No dose adjustment required, but monitor closely 4
  • Severe impairment: Treatment course should not be repeated more than once every two weeks 4
  • Dialysis patients: Reduce to single dose of 0.6 mg, do not repeat more than once every two weeks 4
• For patients with hepatic impairment receiving colchicine:
  • Mild to moderate impairment: No dose adjustment required, but monitor closely 4
  • Severe impairment: Treatment course should not be repeated more than once every two weeks 4

Long-term Management of Chronic Gout

• Urate-lowering therapy (ULT) is indicated for patients with: 1, 3
  • Recurrent acute attacks
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout
• The American College of Physicians recommends against initiating ULT after a first gout attack or in patients with infrequent attacks 3
• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options for ULT 1, 2
• Allopurinol starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 2
• Target serum urate level should be below 6 mg/dL 1, 3
• Uricosuric agents (probenecid, benzbromarone) are alternatives in patients with normal renal function and no history of urolithiasis 3, 5

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis should be initiated whenever ULT is started to prevent flares 1, 3
• First-line prophylactic options include:
  • Low-dose colchicine (0.5-0.6 mg once or twice daily) 1, 2
  • Low-dose NSAIDs with gastroprotection if indicated 1, 3
  • Low-dose prednisone 3
• Duration of prophylaxis should be: 1, 2
  • 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

Non-Pharmacologic Measures

• Weight loss is recommended for obese patients 1, 3
• Avoid alcoholic drinks, especially beer 1, 3
• Avoid beverages sweetened with high-fructose corn syrup 1, 6
• Limit consumption of purine-rich foods (e.g., organ meats, shellfish) 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products 6

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1, 3
• High-dose colchicine regimens cause significant gastrointestinal side effects; low-dose regimens are equally effective with fewer adverse events 1, 3
• Discontinuing ULT during acute attacks can worsen outcomes 1, 3
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 1, 3
• Drug interactions, particularly with colchicine, should be considered to avoid serious toxicity 3
• Inappropriate use of medications rather than true refractoriness to therapy is not uncommon 7