What is the recommended management for gouty arthritis?

Management of Gouty Arthritis

The recommended management for gouty arthritis includes prompt treatment of acute attacks with NSAIDs, colchicine, or corticosteroids, followed by long-term urate-lowering therapy with prophylaxis to prevent recurrent flares. 1, 2

Acute Gout Attack Management

First-Line Treatment Options

• Initiate pharmacologic treatment within 24 hours of symptom onset for optimal outcomes 1
• NSAIDs at full FDA-approved anti-inflammatory doses (e.g., naproxen, indomethacin, sulindac) should be continued until the attack completely resolves 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is effective with fewer gastrointestinal side effects when started within 36 hours of symptom onset 1, 2
• Oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days) are particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2
• Intra-articular corticosteroid injection is highly effective for single joint involvement 1, 3

Treatment Based on Joint Involvement

• For 1-2 large joints or a few small joints, monotherapy with any of the above options is appropriate 1
• For severe pain (≥7/10) or polyarticular involvement (≥4 joints), combination therapy should be considered 1, 3
• Acceptable combination approaches include:
  • Colchicine and NSAIDs
  • Oral corticosteroids and colchicine
  • Intra-articular steroids with any other modality 1, 3

Management of Inadequate Response

• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours of starting therapy 1, 3
• For patients not responding to initial monotherapy, adding a second appropriate agent is recommended 1, 3

Long-term Management of Chronic Gout

Urate-Lowering Therapy (ULT)

• Indicated for patients with recurrent acute attacks, tophi, chronic gouty arthropathy, or radiographic changes of gout 2, 3
• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options 2, 4
• Target serum urate level should be below 6 mg/dL 2, 4
• When initiating allopurinol, start with 100 mg daily and increase at weekly intervals by 100 mg until target urate level is achieved (maximum 800 mg daily) 4
• Ongoing ULT should NOT be interrupted during an acute gout attack 1, 2

Anti-inflammatory Prophylaxis

• Prophylaxis is mandatory when starting ULT to prevent flares 2, 3
• First-line prophylactic options include:
  • Low-dose colchicine (0.6 mg once or twice daily) 1, 2
  • Low-dose NSAIDs with proton pump inhibitor when indicated (e.g., naproxen 250 mg twice daily) 1, 3
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1, 2

Duration of Prophylaxis

• Treatment should continue for:
  • 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

Special Considerations

Renal Impairment

• Corticosteroids are preferred over NSAIDs or colchicine in patients with significant renal disease 3, 5
• Allopurinol dosage should be reduced in renal impairment:
  • With creatinine clearance 10-20 mL/min: 200 mg daily
  • With creatinine clearance <10 mL/min: 100 mg daily 4
• Colchicine dosing requires adjustment in moderate to severe renal impairment 1, 5

Drug Interactions

• Colchicine dose reduction or avoidance is necessary with moderate to high potency inhibitors of cytochrome P450 3A4 and P-glycoprotein (e.g., clarithromycin, erythromycin, cyclosporine) 1, 3
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 2, 3

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 1, 2
• High-dose colchicine regimens cause significant gastrointestinal side effects with no additional benefit 1, 3
• Discontinuing ULT during acute attacks can worsen outcomes 2, 4
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 2, 4
• Inadequate fluid intake may increase risk of xanthine calculi or renal precipitation of urates 4, 6