What are the management options for gout?

Gout Diagnosis and Management

Diagnosis

Gout is diagnosed clinically using validated criteria from the American College of Rheumatology, with definitive confirmation by identifying monosodium urate crystals in synovial fluid of the affected joint. 1

• The classic presentation includes sudden-onset severe pain, swelling, and tenderness in a peripheral joint (most commonly the first metatarsophalangeal joint). 1, 2
• Arthrocentesis should be performed when septic arthritis cannot be excluded or when the diagnosis is uncertain. 2
• Serum uric acid levels alone are insufficient for diagnosis, as they may be normal during acute attacks. 3

Management of Acute Gout Attacks

Acute gout flares must be treated as early as possible—ideally within 12-24 hours of symptom onset—with first-line options including colchicine, NSAIDs, or corticosteroids. 4, 5

First-Line Treatment Options

• Colchicine: Loading dose of 1 mg followed by 0.5 mg one hour later (total 1.5 mg on day 1), most effective when started within 12 hours of flare onset. 4, 6, 5
• NSAIDs: Full anti-inflammatory doses with proton pump inhibitor gastroprotection if appropriate. 4, 5
• Oral corticosteroids: Prednisolone 30-35 mg/day for 3-5 days, particularly useful when NSAIDs or colchicine are contraindicated. 4, 6, 5
• Intra-articular corticosteroid injection: Highly effective for single joint involvement. 5

Critical Contraindications and Adjustments

• Avoid colchicine and NSAIDs in severe renal impairment (CrCl <30 mL/min). 4
• Never co-prescribe colchicine with strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin) due to risk of fatal toxicity. 4, 5
• For patients with heart failure, peptic ulcer disease, or significant renal disease, avoid NSAIDs and use corticosteroids instead. 5

Patient Education for Self-Management

• Educate patients to self-medicate at the first warning symptoms using a "pill in the pocket" approach. 4, 5
• Continue established urate-lowering therapy without interruption during acute attacks. 5

Long-Term Management: Urate-Lowering Therapy (ULT)

All patients with tophaceous gout, radiographic damage, frequent flares (≥2 per year), chronic kidney disease, or urolithiasis should receive lifelong urate-lowering therapy with a treat-to-target approach aiming for serum urate <6 mg/dL. 4

Indications for ULT

• Strong indications: Tophaceous gout, radiographic damage, frequent flares (≥2/year), chronic kidney disease, urolithiasis. 4
• Do NOT initiate after a first gout attack or in patients with infrequent attacks. 4, 5

First-Line ULT: Allopurinol

Allopurinol is the preferred first-line urate-lowering therapy, including for patients with moderate-to-severe chronic kidney disease (stage ≥3). 4, 3

• Starting dose: 100 mg/day (lower in CKD: 50 mg/day if CrCl 10-20 mL/min; ≤100 mg if CrCl <10 mL/min). 4, 6, 3
• Dose titration: Increase by 100 mg every 2-4 weeks until serum urate <6 mg/dL is achieved. 6, 3
• Maximum dose: 800 mg/day. 3
• Target: Serum urate <6 mg/dL (360 μmol/L), maintained lifelong. 4, 6

Alternative ULT Options

• Febuxostat: Start at <40 mg/day, but note increased all-cause and cardiovascular mortality risk—not routinely recommended as first-line. 4, 2
• Uricosuric agents (probenecid, benzbromarone): Reserved for patients with normal renal function, no history of urolithiasis, and contraindications to xanthine oxidase inhibitors. 4, 5

Mandatory Flare Prophylaxis During ULT Initiation

When initiating urate-lowering therapy, concomitant anti-inflammatory prophylaxis for at least 3-6 months is strongly recommended to prevent mobilization flares. 4

• Colchicine: 0.5-1 mg/day (reduce to 0.5 mg daily or every other day if CrCl 30-50 mL/min). 4, 6, 5
• Alternative prophylaxis: Low-dose NSAIDs with gastroprotection or low-dose prednisone if colchicine contraindicated. 4, 5
• Duration: Minimum 6 months, or 3 months after achieving target serum urate if no tophi present, or 6 months after achieving target if tophi present. 5

Lifestyle Modifications and Comorbidity Management

Every patient with gout must receive comprehensive lifestyle counseling and systematic screening for cardiovascular comorbidities, as these interventions reduce both hyperuricemia and mortality. 4, 6

Dietary Recommendations

• Weight loss if obese. 4, 6, 5
• Avoid: Alcohol (especially beer and spirits), sugar-sweetened drinks, excessive red meat and seafood. 4, 6, 5
• Encourage: Low-fat dairy products, regular exercise. 4, 6

Medication Adjustments for Comorbidities

• Diuretics are the most common iatrogenic cause of gout—substitute if possible. 6
• Switch to: Losartan (modest uricosuric effects) or calcium channel blockers for hypertension. 6
• Consider fenofibrate for hyperlipidemia (has uricosuric properties). 6

Comorbidity Screening

• Systematically screen for renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidemia, hypertension, diabetes, and smoking. 4
• Treating associated comorbidities may reduce hyperuricemia and is essential for reducing mortality. 6

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness. 5
• Discontinuing ULT during acute flares—this worsens outcomes and should never be done. 5
• Inadequate prophylaxis duration when starting ULT leads to breakthrough flares and poor adherence. 5
• High-dose colchicine regimens cause severe gastrointestinal toxicity with no additional benefit over low-dose regimens. 5
• Insufficient allopurinol dosing—most patients require >300 mg/day to achieve target serum urate, yet many remain undertreated. 4