What are the treatment options for gout?

Treatment Options for Gout

The first-line treatments for acute gout attacks include NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (0.5 mg/kg per day for 5-10 days), which should be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2, 3

Management of Acute Gout Attacks

• Pharmacologic therapy should be initiated within 24 hours of symptom onset for optimal effectiveness 1
• 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 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 severe or polyarticular attacks, combination therapy may be appropriate 2, 3
• Topical ice application is recommended as an adjunctive measure during acute attacks 1, 3
• Established urate-lowering therapy should be continued without interruption during acute attacks 1, 3

Special Considerations for Medication Selection

• NSAIDs should be avoided in patients with renal disease, heart failure, peptic ulcer disease, or cirrhosis 2, 3
• Colchicine requires dose adjustment in patients with renal impairment:
  • For severe renal impairment, treatment course should not be repeated more than once every two weeks 4
  • For patients undergoing dialysis, the total recommended dose should be reduced to a single dose of 0.6 mg 4
• Corticosteroids are preferred in patients with contraindications to NSAIDs or colchicine 2, 3

Long-term Management of Chronic Gout

• Urate-lowering therapy (ULT) is indicated for patients with: 1, 2, 3
  • Recurrent acute attacks
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout
• First-line options for ULT include xanthine oxidase inhibitors: 1, 2, 3
  • Allopurinol (starting at 100 mg/day, or 50 mg/day in stage 4 or worse CKD)
  • Febuxostat
• The target serum urate level should be below 6 mg/dL 1, 2, 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 1, 2, 3
• First-line prophylactic options include: 1, 2, 3
  • Low-dose colchicine (0.5-0.6 mg once or twice daily)
  • Low-dose NSAIDs with gastroprotection if indicated
• Prophylaxis duration should be: 1, 2, 3
  • 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, 2, 3
• Avoid alcoholic drinks, especially beer 1, 3, 6
• Avoid beverages sweetened with high-fructose corn syrup 1, 3, 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, while low-dose regimens are equally effective with fewer adverse events 1, 3, 7
• 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 with colchicine must be considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors 3, 4
• Colchicine requires dose adjustment in patients with hepatic impairment 4