What are the treatment options for gout?

Treatment Options for Gout

The American College of Rheumatology recommends a comprehensive approach to gout management that includes NSAIDs, colchicine, or corticosteroids for acute attacks, and xanthine oxidase inhibitors (allopurinol or febuxostat) as first-line urate-lowering therapy for long-term management. 1, 2, 3

Acute Gout Attack Management

• Pharmacologic therapy should be initiated within 24 hours of symptom onset for optimal outcomes 2

• For mild-moderate attacks (1-2 joints), choose one of the following monotherapies:

  • NSAIDs at full anti-inflammatory doses (e.g., naproxen, indomethacin) 1, 3
  • Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) - most effective when started within 12 hours of symptom onset 1, 3
  • Oral corticosteroids (prednisone 30-35 mg/day for 3-5 days or 0.5 mg/kg per day for 5-10 days) 1, 3
  • Intra-articular corticosteroid injection for accessible single joint involvement 3

• For severe/polyarticular attacks (≥4 joints), consider combination therapy or intra-articular injections for accessible joints 1, 3

• Topical ice application is recommended as an adjunctive measure during acute attacks 2, 3

Important Considerations for Acute Management

• NSAIDs should be avoided in patients with renal disease, heart failure, or cirrhosis 1, 3
• For patients with renal impairment requiring colchicine, dose adjustments are necessary:
  • For severe renal impairment: treatment course should not be repeated more than once every two weeks 4
  • For dialysis patients: reduce to a single dose of 0.6 mg 4
• Continuing established urate-lowering therapy during acute attacks is recommended 2, 3

Long-Term Management of Chronic Gout

• Indications for urate-lowering therapy (ULT) include:

  • Recurrent acute attacks
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout
  • Urate nephrolithiasis 2, 3

• First-line options for ULT:

  • Xanthine oxidase inhibitors (allopurinol or febuxostat) 1, 2, 3
  • Allopurinol starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 1

• Target serum urate level should be below 6 mg/dL (357 μmol/L) 1, 2, 3

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis should be initiated with or just before starting ULT 1, 3

• First-line prophylactic options:

  • Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) 1, 2, 3
  • Low-dose NSAIDs with gastroprotection if indicated 2, 3
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 3

• Duration of prophylaxis:

  • For patients without tophi: continue for 6 months or 3 months after achieving target serum urate 1, 2, 3
  • For patients with tophi: continue for 6 months after achieving target serum urate and resolution of tophi 1, 2

Lifestyle Modifications

• Weight loss is recommended for obese patients 1, 2, 3
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 2, 3, 5
• Encourage consumption of vegetables and low-fat or nonfat dairy products 5
• Limit consumption of purine-rich foods (e.g., organ meats, shellfish) 5

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 2, 3
• High-dose colchicine regimens cause significant gastrointestinal side effects, while low-dose regimens are equally effective with fewer adverse events 2, 3
• Discontinuing ULT during acute attacks can worsen outcomes 2, 3
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 2, 3
• Treatment of gout flares with colchicine is not recommended in patients with hepatic or renal impairment who are already receiving colchicine for prophylaxis 4