What are the guidelines for managing gout?

Guidelines for Gout Management

The management of gout should follow a comprehensive approach addressing acute attacks, long-term urate-lowering therapy, and prophylaxis to prevent flares during treatment initiation. 1, 2

Acute Gout Attack Management

• Pharmacologic therapy should be initiated within 24 hours of symptom onset for optimal outcomes 2
• First-line options for acute gout attacks include:
  • NSAIDs at full anti-inflammatory doses 3, 2
  • Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) - most effective when started within 12 hours 1, 2
  • Oral corticosteroids (prednisone 30-35 mg/day for 3-5 days or 0.5 mg/kg/day for 5-10 days) 1, 2
  • Intra-articular corticosteroid injection for 1-2 affected joints 2
• For polyarticular attacks (4+ joints) or severe attacks, combination therapy may be appropriate 1, 4
• Established urate-lowering therapy should be continued without interruption during acute attacks 2
• Topical ice application is recommended as an adjunctive measure during acute attacks 2

Long-Term Management of Chronic Gout

• Urate-lowering therapy (ULT) is indicated for patients with: 2

  • Recurrent acute attacks (≥2 per year)
  • Tophi
  • Chronic gouty arthropathy
  • Radiographic changes of gout
  • Urate nephrolithiasis

• Xanthine oxidase inhibitors (allopurinol, febuxostat) are first-line options for ULT 1, 2

• Allopurinol dosing recommendations: 5

  • Starting dose should be no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 3
  • Gradually titrate dose upward every 2-5 weeks to reach target serum urate 3, 5
  • Average dose is 200-300 mg/day for mild gout and 400-600 mg/day for moderately severe tophaceous gout 5
  • Maximum recommended dose is 800 mg daily 5

• Target serum urate level should be below 6 mg/dL 1, 2

• Uricosuric agents (probenecid) are alternative options when xanthine oxidase inhibitors cannot be used 3

Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis should be initiated with or just before starting ULT 1, 2
• First-line prophylactic options: 1, 2
  • Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function)
  • Low-dose NSAIDs with gastroprotection if indicated
• Duration of prophylaxis: 1, 2
  • For patients without tophi: continue for the greater of 6 months duration or 3 months after achieving target serum urate
  • For patients with tophi: continue for 6 months after achieving target serum urate and resolution of tophi

Lifestyle Modifications

• Weight loss is recommended for obese patients 1, 2
• Avoid alcoholic beverages, especially beer and spirits 1, 2
• Avoid beverages sweetened with high-fructose corn syrup 1, 2
• Limit consumption of purine-rich foods (organ meats, shellfish) 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products 6
• Maintain adequate fluid intake (at least 2 liters daily) 5

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 2
• High-dose colchicine regimens cause significant gastrointestinal side effects; low-dose regimens are equally effective with fewer adverse events 2
• Discontinuing ULT during acute attacks can worsen outcomes 2, 7
• Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 2
• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 2
• Allopurinol dose should be adjusted in patients with renal impairment 5
• Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with CKD, Han Chinese, Thai) 3