What is the treatment for gout?

Treatment of Gout

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

Management of Acute Gout Attacks

First-Line Treatment Options

• NSAIDs at full anti-inflammatory doses (such as naproxen, indomethacin, or sulindac) are effective when started promptly and continued until the attack completely resolves 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 when started within 36 hours of symptom onset 2, 1
• Oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days) are particularly useful for patients with contraindications to NSAIDs or colchicine 2
• Intra-articular corticosteroid injection is highly effective for single joint involvement 1, 3

Treatment Algorithm Based on Joint Involvement

• For attacks involving 1-3 small joints or 1-2 large joints, monotherapy with any of the above options is appropriate 2, 3
• For severe pain or polyarticular involvement (≥4 joints), combination therapy should be considered 1, 3
• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours of starting therapy 2

Special Considerations

• For patients with renal impairment:
  • Mild to moderate impairment: No dose adjustment needed for colchicine, but monitor closely 4
  • Severe impairment: Colchicine treatment course should not be repeated more than once every two weeks 4
  • Dialysis patients: Reduce colchicine to single dose of 0.6 mg 4
• For patients with hepatic impairment:
  • Mild to moderate impairment: No dose adjustment needed for colchicine 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)

• ULT is indicated for patients with:
  • Recurrent acute attacks
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout 1, 3
• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options 1, 5
• Target serum urate level should be below 6 mg/dL 1, 3
• Ongoing ULT should NOT be interrupted during an acute gout attack 2, 1

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis is mandatory when starting ULT to prevent flares 1, 3
• First-line prophylactic options:
  • Low-dose colchicine (0.6 mg once or twice daily) 2, 1
  • Low-dose NSAIDs with gastroprotection if indicated 2, 3
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 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, 1

Non-Pharmacologic Measures

• Topical ice application is recommended as an adjunctive measure during acute attacks 1, 3
• Weight loss is recommended for obese patients 1, 5
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 1, 5
• Limit consumption of purine-rich foods (organ meats, shellfish) 5
• Encourage consumption of vegetables and low-fat dairy products 5

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 1, 3
• High-dose colchicine regimens cause significant gastrointestinal side effects with no additional benefit 1, 6
• Discontinuing ULT during acute attacks can worsen outcomes 2, 1
• 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 1, 4
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 3