Treatment Options for Gout
For acute gout attacks, corticosteroids, NSAIDs, or low-dose colchicine should be initiated within 24 hours of symptom onset for optimal outcomes, with corticosteroids considered as first-line therapy due to their favorable safety profile when there are no contraindications. 1, 2
Acute Gout Attack Management
First-Line Treatment Options
- Corticosteroids (oral prednisolone 35mg for 5 days) are generally safer and a low-cost treatment option, and should be considered first-line therapy in patients without contraindications 3
- NSAIDs at full anti-inflammatory doses are effective when started promptly, with no evidence that indomethacin is more efficacious than other NSAIDs 3, 1
- Low-dose colchicine (1.2mg followed by 0.6mg one hour later) is as effective as higher doses with fewer gastrointestinal side effects 3, 1
- Intra-articular corticosteroid injection is highly effective for single joint involvement 1, 2
Treatment Algorithm Based on Joint Involvement
- For 1-3 small joints or 1-2 large joints, monotherapy with one of the above options is appropriate 2
- For polyarticular involvement (≥4 joints), combination therapy may be considered 1
- Topical ice application is recommended as an adjunctive measure during acute attacks 1, 2
Special Considerations
- For patients with renal impairment, corticosteroids are safer than NSAIDs or colchicine 1
- For patients with severe renal impairment (CrCl <30 mL/min), colchicine dosing should be adjusted and treatment courses should not be repeated more than once every two weeks 4
- For patients with severe hepatic impairment, colchicine treatment courses should not be repeated more than once every two weeks 4
- Continuing established urate-lowering therapy without interruption during acute attacks is recommended 1, 2
Long-term Management of Chronic Gout
Indications for Urate-Lowering Therapy (ULT)
- The American College of Physicians recommends against initiating ULT after a first gout attack or in patients with infrequent attacks 3, 1
- ULT is indicated for patients with:
Urate-Lowering Options
- Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options 1, 2, 5
- Uricosuric agents (probenecid, benzbromarone) are alternatives in patients with normal renal function and no history of urolithiasis 1, 6
- Target serum urate level should be below 6 mg/dL 1, 2
Prophylaxis During Urate-Lowering Therapy
- Anti-inflammatory prophylaxis is strongly recommended when starting ULT to prevent flares 1, 2
- Prophylactic options include:
- 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 1, 2, 5
Non-Pharmacologic Measures
- Weight loss is recommended for obese patients 1, 2
- Avoid alcoholic drinks, especially beer 1, 2, 5
- Avoid beverages sweetened with high-fructose corn syrup 1, 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
- Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1, 2
- High-dose colchicine regimens cause significant gastrointestinal side effects, while low-dose regimens are equally effective with fewer adverse events 3, 1
- Discontinuing ULT during acute attacks can worsen outcomes 1, 2
- Inadequate duration of prophylaxis when initiating ULT 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 1, 2
- Drug interactions with colchicine must be considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors 1