What is the best treatment for gout?

Best Treatment for Gout

The optimal treatment for gout requires a dual approach: immediate anti-inflammatory therapy for acute flares (NSAIDs, colchicine, or corticosteroids) combined with long-term urate-lowering therapy (allopurinol as first-line) to achieve and maintain serum urate below 6 mg/dL, with mandatory prophylaxis during the first 3-6 months of urate-lowering therapy initiation. 1

Acute Gout Flare Management

For acute attacks, start anti-inflammatory treatment immediately—the speed of initiation matters more than which specific agent you choose. 1

First-Line Options for Acute Flares (all equally effective):

• NSAIDs at full anti-inflammatory doses are strongly recommended as first-line therapy for acute gout flares 1, 2

  • Naproxen 500-750 mg initially, then 250-500 mg twice daily is effective 2
  • Response typically occurs within 24-48 hours with significant reduction in swelling and pain 2

• Colchicine using the low-dose regimen (1.2 mg initially, then 0.6 mg one hour later, total 1.8 mg) is strongly recommended 1, 3

  • The low-dose regimen (1.8 mg total) achieves 38% response rate versus 16% for placebo at 24 hours 3
  • Critical pitfall: Avoid the outdated high-dose regimen (4.8 mg total)—it provides no additional benefit but causes significantly more gastrointestinal toxicity 3

• Corticosteroids (oral, intraarticular, or intramuscular) are strongly recommended, particularly when NSAIDs and colchicine are contraindicated 1

  • Prednisone 30-40 mg daily for 5-7 days is typical dosing 1
  • Intraarticular injection is highly effective for monoarticular attacks 1

Adjunctive Measures:

• Apply ice to the affected joint and rest it during acute attacks 1

Long-Term Urate-Lowering Therapy (ULT)

Initiate ULT for all patients with tophaceous gout, radiographic damage, or frequent flares (≥2 per year). 1

First-Line ULT:

• Allopurinol is the preferred first-line urate-lowering agent for all patients, including those with moderate-to-severe chronic kidney disease (CKD stage ≥3) 1
  • Start low: Begin at ≤100 mg/day (lower doses in CKD) to minimize flare risk 1
  • Titrate to target: Increase dose every 2-5 weeks based on serum urate measurements 1
  • Target serum urate <6 mg/dL (some patients with tophi may benefit from <5 mg/dL) 1
  • Critical consideration: In Southeast Asian and Black populations, screen for HLA-B*5801 before starting allopurinol to prevent severe hypersensitivity reactions 4

Second-Line ULT:

• Febuxostat (<40 mg/day starting dose) is an alternative xanthine oxidase inhibitor 1
  • Reserve for patients who cannot tolerate or fail allopurinol 1
  • Important warning: FDA black box warning for cardiovascular mortality—use with caution in patients with cardiovascular disease 4

Uricosuric Agents:

• Probenecid is reserved for patients intolerant to xanthine oxidase inhibitors 1, 5
  • Avoid in patients with kidney stones or significant renal impairment 1

Mandatory Prophylaxis During ULT Initiation

When starting any urate-lowering therapy, you must provide concomitant anti-inflammatory prophylaxis for at least 3-6 months. 1

Prophylaxis Options:

• Colchicine 0.5-0.6 mg once or twice daily is the preferred prophylactic agent 1, 5
• Low-dose NSAIDs are an alternative if colchicine is contraindicated 1
• Low-dose corticosteroids (e.g., prednisone ≤10 mg/day) if both colchicine and NSAIDs are contraindicated 1

Continue prophylaxis for at least 3 months after achieving target serum urate in patients without tophi, or 6 months in those with a history of tophi. 1, 5

Lifestyle Modifications

Address modifiable risk factors as part of comprehensive gout management: 1

• Weight reduction if obese 1, 5
• Limit alcohol consumption, especially beer 1, 5
• Avoid high-fructose corn syrup and sugar-sweetened beverages 5
• Reduce intake of purine-rich foods (organ meats, shellfish) 5
• Encourage low-fat dairy products and vegetables 5
• Review medications: Consider alternatives to thiazide and loop diuretics when possible; losartan may have uricosuric benefits 5, 6

Treatment Algorithm by Clinical Scenario

Acute Monoarticular Attack:

1. Joint aspiration with intraarticular corticosteroid injection (if accessible) 1
2. OR oral NSAID at full anti-inflammatory dose 1
3. OR low-dose colchicine (1.8 mg total over 1 hour) 1, 3

Acute Polyarticular Attack:

1. Oral corticosteroids (prednisone 30-40 mg daily) 1
2. OR combination of colchicine plus NSAID 1

Patient with Frequent Flares (≥2/year):

1. Initiate allopurinol 100 mg/day or less 1
2. Start prophylactic colchicine 0.5-0.6 mg daily simultaneously 1
3. Titrate allopurinol every 2-5 weeks to achieve serum urate <6 mg/dL 1
4. Continue prophylaxis for 3-6 months after reaching target 1

Patient with Tophaceous Gout:

1. Mandatory ULT initiation regardless of flare frequency 1
2. Target serum urate <5 mg/dL for faster tophi resolution 1
3. Extended prophylaxis (6 months minimum) 1, 5

Common Pitfalls to Avoid

• Never start or stop urate-lowering therapy during an acute flare—continue existing ULT but don't initiate new ULT until the flare resolves 1
• Don't use high-dose colchicine regimens (>1.8 mg in first hour)—they cause severe GI toxicity without added benefit 3
• Don't start allopurinol at high doses—this triggers flares and reduces adherence 1
• Don't forget prophylaxis when initiating ULT—this is the most common cause of treatment failure and patient abandonment of therapy 1
• Don't treat asymptomatic hyperuricemia without gout—there's no evidence supporting this approach 1
• Avoid uricosuric agents in patients with kidney stones or significant renal impairment 1
• Adjust colchicine dosing with strong CYP3A4 inhibitors (clarithromycin, cyclosporine)—risk of severe toxicity 7