What are the treatment options for gout?

Treatment for Gout

For acute gout attacks, initiate treatment within 24 hours using NSAIDs, oral corticosteroids, or low-dose colchicine as first-line monotherapy options, with choice based on attack severity, joint involvement, and patient comorbidities. 1

Acute Gout Attack Management

General Principles

• Start pharmacologic therapy within 24 hours of symptom onset to optimize pain relief and functional recovery 1
• Continue established urate-lowering therapy (ULT) without interruption during acute attacks—stopping ULT worsens outcomes 1
• Apply topical ice to affected joints as an adjunctive measure 1, 2

Treatment Selection Based on Attack Severity

For mild-to-moderate attacks (pain ≤6/10) involving 1-3 small joints or 1-2 large joints:

• Choose one of the following first-line monotherapy options 1:
  • NSAIDs at full anti-inflammatory doses (naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily) continued until complete resolution 1, 2
  • Oral corticosteroids: prednisone 0.5 mg/kg/day for 5-10 days at full dose then stop, OR 2-5 days at full dose then taper over 7-10 days 1, 2
  • Low-dose colchicine: 1.2 mg followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours), only if started within 36 hours of symptom onset 1, 3

For severe attacks (pain ≥7/10) or polyarticular involvement (≥4 joints):

• Use combination therapy from the start 1, 4:
  • Colchicine + NSAIDs, OR
  • Oral corticosteroids + colchicine, OR
  • Intra-articular corticosteroids + any oral agent 1, 4

For single joint involvement:

• Intra-articular corticosteroid injection is highly effective (dose varies by joint size) 1, 2, 4

Special Populations

NPO (nothing by mouth) patients:

• Intra-articular corticosteroid injection for 1-2 affected joints 1, 4
• For multiple joints: IV/IM methylprednisolone 0.5-2.0 mg/kg OR subcutaneous ACTH 25-40 IU 1, 4

Patients with renal impairment:

• Corticosteroids are safer than NSAIDs or colchicine 4
• For colchicine dosing in renal impairment: no dose adjustment needed for mild-moderate impairment (CrCl 30-80 mL/min), but monitor closely 3
• For severe renal impairment (CrCl <30 mL/min): colchicine treatment course should not be repeated more than once every two weeks 3
• For dialysis patients: single dose of 0.6 mg colchicine only, not repeated more than once every two weeks 3

Patients with contraindications to NSAIDs (heart failure, peptic ulcer disease, significant renal disease):

• Use corticosteroids or colchicine instead 1, 2

Managing Inadequate Response

• Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours 1, 2
• Switch to another monotherapy agent OR add a second appropriate agent 1, 4

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

• Initiate ULT in patients with: 1, 5, 2
  • Recurrent acute attacks (≥2 per year)
  • Tophi (palpable or on imaging)
  • Chronic gouty arthropathy
  • Radiographic changes of gout
  • Urolithiasis
  • Chronic kidney disease

First-Line ULT Options

• Xanthine oxidase inhibitors are first-line: 1, 5, 2
  • Allopurinol: start at ≤100 mg/day (50 mg/day if CrCl <60 mL/min or stage 4+ CKD), titrate to achieve target serum urate 5
  • Febuxostat: alternative option, though associated with increased cardiovascular and all-cause mortality 6

Target Serum Urate Level

• Maintain serum urate <6 mg/dL (357 μmol/L) 1, 5, 2

Alternative ULT Options

• Uricosuric agents (probenecid, benzbromarone) for patients with normal renal function, no urolithiasis history, and allopurinol intolerance 1, 4, 7

Anti-Inflammatory Prophylaxis During ULT Initiation

When to Initiate Prophylaxis

• Start prophylaxis with or just before initiating ULT in all patients 1, 5

First-Line Prophylaxis Options

• Low-dose colchicine 0.6 mg once or twice daily (adjust for renal impairment and drug interactions) 1, 5
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with proton pump inhibitor where indicated 1, 5

Second-Line Prophylaxis

• Low-dose prednisone or prednisolone (<10 mg/day) if colchicine and NSAIDs are contraindicated or not tolerated 1, 5, 2

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 5

• At least 6 months, OR
• 3 months after achieving target serum urate (if no tophi present), OR
• 6 months after achieving target serum urate AND resolution of tophi (if tophi were present)

Lifestyle Modifications

• Weight loss if obese 5, 2, 4
• Avoid alcohol (especially beer and spirits) 1, 5, 8
• Avoid beverages sweetened with high-fructose corn syrup 5, 8
• Limit purine-rich foods (organ meats, shellfish) 8
• Encourage low-fat or nonfat dairy products and vegetables 8
• Consider stopping diuretics if possible when gout is associated with diuretic use 1

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2, 4
• Never stop ULT during acute attacks—this worsens disease control 1, 2
• Failing to provide prophylaxis when starting ULT leads to acute flares and poor adherence 1, 2
• High-dose colchicine regimens cause severe GI toxicity without additional benefit—use only low-dose regimens 4, 3
• Colchicine is ineffective if started >36 hours after symptom onset 1
• Monitor for drug-drug interactions with colchicine, particularly with P-glycoprotein/CYP3A4 inhibitors (cyclosporine, clarithromycin) 1, 4, 3
• Avoid NSAIDs in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 2, 4