What medications are recommended for acute and prophylactic treatment of gout?

Medications for Gout Management: Acute and Prophylactic Treatment

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

Acute Gout Treatment

First-Line Options:

• Corticosteroids: Considered first-line therapy in patients without contraindications due to their safety profile and low cost 1, 3

  • Prednisolone 35 mg daily for 5 days is effective for acute gout 1, 3
  • Alternative dosing: oral prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 3
  • Intra-articular corticosteroid injection is highly effective for single joint involvement 1, 2

• NSAIDs: Should be used at full FDA-approved anti-inflammatory/analgesic doses 1

  • FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 1
  • No evidence that indomethacin is more efficacious than other NSAIDs 1, 3
  • Contraindicated in patients with renal disease, heart failure, or cirrhosis 1

• Colchicine: Effective when started within 36 hours of symptom onset 1

  • Low-dose regimen: 1.2 mg followed by 0.6 mg 1 hour later 1, 4
  • This regimen is as effective as higher doses with fewer gastrointestinal side effects 3, 4
  • After initial dosing, may continue with 0.6 mg once or twice daily until attack resolves 1, 4

Treatment Algorithm Based on Severity and Joint Involvement:

• Mild to moderate pain (≤6/10) with limited joint involvement: Monotherapy with any first-line agent 1, 2

• Severe pain (≥7/10) or polyarticular involvement: Consider combination therapy 1, 2

  • Effective combinations include:
    • Colchicine plus NSAIDs 1, 2
    • Oral corticosteroids plus colchicine 1, 2
    • Intra-articular steroids with any other modality 1, 2

Prophylactic Treatment

Indications for Prophylaxis:

• Prophylaxis is strongly recommended when starting urate-lowering therapy to prevent flares 1, 2
• Prophylactic therapy should be continued for more than 8 weeks when initiating urate-lowering therapy 1

Prophylactic Options:

• Colchicine: First-line option for gout attack prophylaxis 1, 2

  • Dosage: 0.6 mg once or twice daily (maximum 1.2 mg/day) 4
  • Requires dose adjustment in chronic kidney disease and for drug interactions 4

• Low-dose NSAIDs: Appropriate choice for first-line gout attack prophylaxis if colchicine is not tolerated 1, 2

• Duration of prophylaxis: 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

Urate-Lowering Therapy (ULT)

• Not recommended after a first gout attack or in patients with infrequent attacks 1, 2
• Indicated for patients with recurrent acute attacks (≥2 per year), tophi, or radiographic changes of gout 5, 2
• Options include:
  • Xanthine oxidase inhibitors: Allopurinol or febuxostat as first-line options 1, 2
  • Uricosuric agents: Probenecid or benzbromarone as alternatives in patients with normal renal function and no history of urolithiasis 2, 6
• Target serum urate level should be below 6 mg/dL 2
• Continue established urate-lowering therapy without interruption during an acute attack 1, 2

Special Considerations and Caveats

• Timing is crucial: Initiating treatment within 24 hours of symptom onset provides best results 1, 2

• Patient-specific factors:

  • For patients with renal impairment: Corticosteroids are generally safer than NSAIDs or colchicine 5, 3
  • For patients with diabetes: NSAIDs or colchicine may be preferred over corticosteroids 3
  • For patients with cardiovascular disease: Corticosteroids or colchicine preferred over NSAIDs 5, 7
  • For patients with gastrointestinal risk factors: Corticosteroids or low-dose colchicine preferred over NSAIDs 3, 7

• Common pitfalls:

  • High-dose colchicine regimens cause significant gastrointestinal side effects with no additional benefit 2, 4
  • Discontinuing urate-lowering therapy during acute flares can worsen outcomes 1, 2
  • Drug interactions with colchicine must be considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors 2, 4
  • Inadequate duration of prophylaxis when initiating urate-lowering therapy can lead to breakthrough flares and poor medication adherence 1, 2

• Patient education: Educate patients to initiate treatment upon first signs of an acute attack ("pill in the pocket" approach) 1, 2