What is the best treatment for gout?

Treatment of Gout: Acute and Chronic Management

Acute Gout Attack Management

For acute gout attacks, first-line treatment options include low-dose colchicine, NSAIDs, or corticosteroids, with treatment selection based on patient comorbidities and contraindications. 1, 2

• Treatment 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 options:

  • Low-dose colchicine: 1.2 mg initially followed by 0.6 mg one hour later (maximum 1.8 mg over 1 hour) 3, 1
  • NSAIDs at full anti-inflammatory doses 4, 1
  • Oral corticosteroids: prednisone 30-35 mg daily for 3-5 days or 0.5 mg/kg daily for 5-10 days 1, 2
  • Intra-articular corticosteroid injection for 1-2 accessible joints 2

• For severe/polyarticular attacks, consider combination therapy or intra-articular injections for accessible joints 1

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

• Continue established urate-lowering therapy without interruption during acute attacks 2

Long-Term Management of Chronic Gout

• Urate-lowering therapy (ULT) is indicated for patients with:

  • Recurrent acute attacks (≥2 attacks per year) 1, 2
  • Presence of tophi 1, 2
  • Chronic gouty arthropathy or radiographic changes of gout 2
  • Urate nephrolithiasis 1

• Xanthine oxidase inhibitors are first-line options for ULT:

  • Allopurinol: Start at low dose (100 mg daily, or 50 mg daily in stage 4 or worse CKD) 4, 1
  • Increase dose by 100 mg every 2-4 weeks until target serum urate is achieved 4
  • Adjust dose in patients with renal impairment 4

• Uricosuric agents (probenecid, sulphinpyrazone) can be used as alternatives to allopurinol in patients with:

  • Normal renal function 4
  • No history of urolithiasis 4

• Target serum urate level should be below 6 mg/dL (0.36 mmol/L) 4, 1, 2

• For patients with tophi, a more stringent target of below 5 mg/dL (0.30 mmol/L) may be appropriate 4

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis should be initiated with or just before starting ULT 1, 2

• Options for prophylaxis include:

  • Low-dose colchicine (0.5-0.6 mg once or twice daily, adjusted for renal function) 1, 2
  • Low-dose NSAIDs with gastroprotection if indicated 2
  • Low-dose corticosteroids if colchicine and NSAIDs are contraindicated 1

• Duration of prophylaxis:

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

Lifestyle Modifications

• Patient education regarding weight loss (if obese), diet, and reduced alcohol consumption is essential 4
• Specific dietary recommendations:
  • Avoid alcohol, especially beer and spirits 4, 1
  • Avoid sugar-sweetened drinks and beverages with high-fructose corn syrup 1, 2
  • Limit consumption of purine-rich foods (organ meats, shellfish) 5
  • Encourage consumption of vegetables and low-fat or nonfat dairy products 5

Common Pitfalls and Caveats

• High-dose colchicine regimens cause significant gastrointestinal side effects; low-dose regimens are equally effective with fewer adverse events 2, 3
• NSAIDs should be avoided in patients with renal disease, heart failure, or cirrhosis 1, 2
• Discontinuing ULT during acute attacks can worsen outcomes 2
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 2
• Pharmacological treatment of asymptomatic hyperuricemia is not recommended to prevent gouty arthritis, renal disease, or cardiovascular events 4