What are the treatment options for gout?

Gout Treatment

For acute gout attacks, start NSAIDs, low-dose colchicine, or oral corticosteroids immediately—within 24 hours of symptom onset—and for long-term management, initiate urate-lowering therapy with allopurinol or febuxostat after multiple attacks, targeting serum urate below 6 mg/dL while providing anti-inflammatory prophylaxis for at least 6 months. 1, 2, 3

Acute Gout Attack Management

First-Line Monotherapy (for 1-3 small joints or 1-2 large joints)

Choose one of the following based on patient contraindications:

• NSAIDs at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) started promptly and continued until complete resolution 1, 2, 3

  • Avoid in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 1, 2, 3

• Low-dose colchicine: 1.2 mg followed by 0.6 mg one hour later 1, 2, 3

  • Most effective when started within 12 hours of symptom onset, but effective up to 36 hours 1, 2
  • Low-dose regimens are equally effective as high-dose with significantly fewer gastrointestinal side effects 2, 3

• Oral corticosteroids: Prednisone 0.5 mg/kg per day for 5-10 days or 30-35 mg/day for 3-5 days 1, 2, 3

  • Particularly useful when NSAIDs and colchicine are contraindicated 2

• Intra-articular corticosteroid injection for single joint involvement 2, 3

Combination Therapy (for severe pain or ≥4 joints involved)

• Use combination therapy for polyarticular attacks or when monotherapy shows inadequate response (defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours) 2, 3

Critical Timing Considerations

• Initiate treatment within 24 hours of symptom onset—delaying beyond this significantly reduces effectiveness 2, 3
• Provide patients with instructions for self-initiation of treatment at first signs of an attack 3
• Continue established urate-lowering therapy without interruption during acute attacks—discontinuing worsens outcomes 2, 3

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate urate-lowering therapy in patients with: 1, 2, 3

• Recurrent acute attacks (multiple attacks)
• Tophi (visible or radiographic)
• Chronic gouty arthropathy
• Urate nephrolithiasis
• Radiographic changes of gout

First-Line ULT Options

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line agents 1, 2, 3

• Allopurinol dosing: Start at no greater than 100 mg/day (50 mg/day in stage 4 or worse CKD), then titrate upward every 2-5 weeks to reach target 1, 3

  • Consider HLA-B*5801 testing before initiating in high-risk populations (Koreans with CKD, Han Chinese, Thai) 3

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

Alternative ULT Options

• Uricosuric agents (probenecid) when xanthine oxidase inhibitors cannot be used 3
  • Preferred in allopurinol-allergic patients and underexcretors with normal renal function and no history of urolithiasis 4

Mandatory Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis must be initiated with or just before starting ULT to prevent flares—failure to provide prophylaxis leads to acute flares and poor medication adherence. 1, 2, 3

First-Line Prophylaxis Options

• Low-dose colchicine: 0.5-0.6 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 2

Duration of Prophylaxis

• For patients without tophi: Continue for the greater of 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, 3

Non-Pharmacologic Measures

• Topical ice application as adjunctive measure during acute attacks 2, 3
• Weight loss for obese patients 1, 2, 3
• Avoid alcohol (especially beer and spirits) and sugar-sweetened beverages with high-fructose corn syrup 1, 2, 3
• Limit purine-rich foods (organ meats, shellfish) 5
• Encourage consumption of vegetables and low-fat or nonfat dairy products 5

Common Pitfalls to Avoid

• Never delay treatment beyond 24 hours—this is the single most important determinant of therapeutic success, not which agent is chosen 2, 3, 6
• Never discontinue ULT during acute attacks—this worsens outcomes and should be continued without interruption 2, 3
• Never start ULT without prophylaxis—this consistently leads to acute flares and treatment abandonment 2, 3
• Never use high-dose colchicine regimens—low-dose is equally effective with far fewer gastrointestinal side effects 2, 3
• Avoid NSAIDs in patients with heart failure, peptic ulcer disease, significant renal disease, or cirrhosis 1, 2, 3