What is the treatment for gout?

Treatment of Gout

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

Acute Gout Attack Management

First-Line Treatment Options

• Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option 2
• NSAIDs at full anti-inflammatory doses are effective when started promptly, with no evidence that indomethacin is more efficacious than other NSAIDs 2, 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is as effective as higher doses with fewer gastrointestinal side effects 2, 1

Medication-Specific Recommendations

• Oral prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or for 2-5 days at full dose followed by 7-10 day taper 2, 1
• Intra-articular corticosteroid injection is highly effective for single joint involvement 2, 1
• For patients not already on prophylactic colchicine, administer 1.2 mg followed by 0.6 mg one hour later 2, 3

Special Considerations

• For patients with renal impairment:
  • Mild to moderate renal impairment: No dose adjustment needed for NSAIDs or colchicine, but monitor closely 3
  • Severe renal impairment: Treatment course with colchicine should not be repeated more than once every two weeks 3
  • Dialysis patients: Reduce colchicine to a single dose of 0.6 mg, not to be repeated more than once every two weeks 3
• For patients with hepatic impairment:
  • Mild to moderate hepatic impairment: No dose adjustment needed, but monitor closely 3
  • Severe hepatic impairment: Treatment course should not be repeated more than once every two weeks 3

Long-term Management of Chronic Gout

Urate-Lowering Therapy (ULT)

• ULT is not recommended after a first gout attack or in patients with infrequent attacks 2, 1
• ULT is indicated for patients with recurrent acute attacks, tophi, or radiographic changes of gout 1, 4
• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options for ULT 1, 4
• Target serum urate level should be below 6 mg/dL 1, 4

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis should be initiated with or just prior to starting ULT 2, 1
• Prophylactic options include:
  • Low-dose colchicine (0.6 mg once or twice daily) as first-line 2, 1
  • Low-dose NSAIDs with gastroprotection as second-line 2, 1
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 2, 5
• Continue prophylaxis for at least 6 months, or 3-6 months after achieving target serum urate levels 1, 4

Non-Pharmacologic Measures

• Weight loss is recommended for obese patients 1, 4
• Avoid alcoholic drinks, especially beer, and beverages sweetened with high-fructose corn syrup 1, 4
• Limit consumption of purine-rich foods (e.g., organ meats, shellfish) 4, 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products 4

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1
• High-dose colchicine regimens cause significant gastrointestinal side effects with no additional benefit 1, 3
• Do not discontinue urate-lowering therapy during acute flares 2, 1
• Inadequate duration of prophylaxis when initiating ULT can lead to breakthrough flares and poor medication adherence 1, 6
• Drug interactions with colchicine must be considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors 1, 3
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 7