What is the best management for recurrent gouty arthritis attacks?

Management of Recurrent Gouty Arthritis Attacks

For patients with recurrent gouty arthritis attacks (≥2 episodes per year), urate-lowering therapy with prophylaxis is recommended after discussing benefits, harms, costs, and individual preferences with the patient. 1

Acute Attack Management

• Use one of the following first-line treatments for acute gout attacks based on patient-specific factors:

  • NSAIDs (no evidence that indomethacin is superior to other NSAIDs like naproxen or ibuprofen) 1
  • Low-dose colchicine (1.2 mg followed by 0.6 mg 1 hour later) which is as effective as higher doses with fewer gastrointestinal side effects 1
  • Corticosteroids (oral, intra-articular, or systemic) for patients with contraindications to NSAIDs or colchicine 1

• Selection should consider:

  • Cost (colchicine is generally more expensive than NSAIDs or corticosteroids) 1
  • Contraindications (avoid NSAIDs in renal disease, heart failure, or cirrhosis; avoid colchicine in renal/hepatic impairment or with certain medications) 1
  • Comorbidities and potential adverse effects 1

Long-Term Management for Recurrent Attacks

Urate-Lowering Therapy (ULT)

• Initiate ULT in patients with:

  • Recurrent gout (≥2 episodes per year) 1
  • Problematic gout (associated with tophi, chronic renal disease, or urolithiasis) 1
  • Serum urate levels >476 µmol/L (>8 mg/dL) who are at greater risk for recurrent attacks 1

• ULT options:

  • Allopurinol: Start at 100 mg daily and increase by 100 mg weekly until serum uric acid level ≤6 mg/dL is achieved (typically 200-300 mg/day for mild gout, 400-600 mg/day for moderate-severe tophaceous gout) 2
  • Febuxostat: 40 mg/day is equally effective as allopurinol 300 mg/day at decreasing serum urate levels 1

• Important considerations:

  • Moderate to high-quality evidence shows ULT reduces risk for acute gout attacks after 1 year, but not within the first 6 months of treatment 1, 3
  • Patients achieving serum urate levels <6.0 mg/dL have fewer gout flares at 12 months 1, 3

Prophylaxis During ULT Initiation

• Always provide prophylaxis when initiating ULT to prevent acute flares 1, 3

  • High-quality evidence shows prophylactic therapy with low-dose colchicine or low-dose NSAIDs reduces the risk for acute gout attacks 1, 3
  • Continue prophylaxis for more than 8 weeks, as evidence shows this is more effective than shorter durations 1, 3
  • The rate of acute gout flares approximately doubles when anti-inflammatory prophylaxis is discontinued after 8 weeks 1, 3

• Prophylaxis options:

  • Low-dose colchicine (0.6 mg twice daily) 1, 3
  • Low-dose NSAIDs 1, 3

Monitoring and Follow-up

• Monitor serum urate levels to achieve target of <6 mg/dL (357 µmol/L) 1, 3
• Patients who attain urate levels <6.0 mg/dL have fewer gout flares at 12 months than those with higher levels 1, 3
• Duration of ULT is typically long-term, though insufficient evidence exists regarding when/if to discontinue therapy 1
• One cohort study suggests ULT might be discontinued in asymptomatic patients who maintained serum urate levels <7 mg/dL after 5 years of treatment 1

Common Pitfalls and Caveats

• Initiating ULT during an acute attack was traditionally avoided, but recent evidence suggests it does not significantly prolong the resolution of acute, treated gout 4
• Rapid lowering of urate levels can paradoxically increase gout flares in the first 6 months due to mobilization of urate crystals from tissue deposits 3
• Failure to provide prophylaxis when starting ULT significantly increases the risk of acute flares 1, 3
• Discontinuing prophylaxis too early (before 8 weeks) increases risk of breakthrough attacks 1
• Inadequate dosing of allopurinol is common - dose should be titrated to achieve target urate level rather than using a fixed dose 2
• Allopurinol dosing should be adjusted in patients with renal impairment 2