What is the recommended treatment for gout?

Treatment of Gout

For acute gout flares, initiate colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs, or oral corticosteroids (30-35 mg prednisolone equivalent for 3-5 days) as first-line therapy within 24 hours of symptom onset; for long-term management, start allopurinol at 100 mg/day and titrate every 2-4 weeks to achieve serum uric acid <6 mg/dL, with mandatory prophylaxis using low-dose colchicine (0.5-1 mg/day) for at least 6 months. 1

Acute Gout Flare Management

First-Line Anti-Inflammatory Options

• Colchicine: FDA-approved dosing is 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later, with maximum dose of 1.8 mg over one hour. 2, 1

  • Low-dose colchicine is strongly preferred over high-dose due to similar efficacy with fewer adverse effects. 1
  • Must be initiated within 12 hours of flare onset for optimal effectiveness. 1
  • Avoid in patients with severe renal impairment (CrCl <30 mL/min) or those taking strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin). 1, 2

• NSAIDs: Any NSAID at full anti-inflammatory dose with proton pump inhibitor if gastrointestinal risk factors present. 1

  • The critical factor is early initiation, not which specific NSAID is chosen. 1, 3
  • Contraindicated in severe renal impairment. 1

• Corticosteroids: Oral prednisolone 30-35 mg/day for 3-5 days, or intra-articular injection for monoarticular involvement. 1

  • Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended when oral medications cannot be taken. 1

Second-Line Options

• IL-1 blockers should be considered only for patients with frequent flares who have contraindications to or cannot tolerate colchicine, NSAIDs, and corticosteroids. 1
  • Current infection is an absolute contraindication. 1

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy. 1

Long-Term Urate-Lowering Therapy (ULT)

When to Initiate

• ULT should be considered from the first presentation of gout, particularly in patients with frequent flares, tophi, erosive arthropathy, or chronic kidney disease. 1
• Do not interrupt ongoing ULT during an acute flare—continue without dose adjustment. 1, 4

Target Serum Uric Acid Levels

• Primary target: <6 mg/dL (360 μmol/L) for all patients with gout. 1
• Intensive target: <5 mg/dL (300 μmol/L) for patients with severe gout (tophi, chronic arthropathy, frequent flares). 1, 4

First-Line ULT: Allopurinol

• Starting dose: 100 mg/day (50-100 mg/day in renal impairment). 1, 4
• Titration: Increase by 100 mg increments every 2-4 weeks until target serum uric acid achieved. 1, 4
• Maximum dose: Up to 800 mg/day in patients with normal renal function if needed to reach target. 1, 4
• Dose adjustment required in renal impairment, but can be used with close monitoring for adverse events. 1, 4

Second-Line ULT Options

• Febuxostat: Consider if allopurinol target not achieved at maximum tolerated dose or if allopurinol not tolerated. 1
• Uricosuric agents (probenecid, benzbromarone): Alternative or add-on therapy, particularly in allopurinol-allergic patients with normal renal function and no history of kidney stones. 1
• Pegloticase: Strongly recommended for refractory gout where xanthine oxidase inhibitors, uricosurics, and other interventions have failed AND patient has frequent flares or nonresolving tophi. 1
  • Strongly recommended against pegloticase in patients with infrequent flares (<2/year) and no tophi due to unfavorable risk-benefit ratio. 1

Mandatory Prophylaxis During ULT Initiation

Rationale and Duration

• Prophylaxis must be initiated with or just prior to starting ULT to prevent mobilization flares. 1, 4, 2
• Minimum duration: 6 months of ULT. 1
• Continue prophylaxis if ongoing gout disease activity or serum urate target not yet achieved. 1

Prophylaxis Options

• Colchicine 0.5-1 mg/day is the recommended first-line prophylactic agent. 1, 2

  • Reduce dose in renal impairment: 0.3 mg/day or 0.3 mg every other day for severe impairment. 2
  • For dialysis patients: 0.3 mg twice weekly. 2

• Low-dose NSAIDs are appropriate alternatives if colchicine contraindicated or not tolerated. 1

• Low-dose corticosteroids (e.g., prednisone ≤10 mg/day) can be used if both colchicine and NSAIDs are contraindicated. 1

Monitoring Protocol

• Check serum uric acid every 2-4 weeks during dose titration until target achieved. 4
• Once stable on maintenance ULT, monitor serum uric acid every 6 months. 4
• Monitor frequency of gout attacks and tophi size as clinical endpoints. 1, 2

Lifestyle Modifications (Essential Adjunct)

• Weight loss if overweight or obese. 1, 4
• Avoid: Alcohol (especially beer and spirits), sugar-sweetened drinks, excessive intake of meat and seafood. 1, 4
• Encourage: Low-fat dairy products, regular exercise. 1, 4

Comorbidity Management

• Systematically screen for and address cardiovascular risk factors, renal impairment, obesity, hyperlipidemia, hypertension, and diabetes. 1
• Consider substituting loop or thiazide diuretics with alternatives when possible. 4
• Consider losartan for hypertension (has uricosuric properties) or calcium channel blockers. 4
• Consider statin or fenofibrate for hyperlipidemia (fenofibrate has mild uricosuric effect). 4

Critical Pitfalls to Avoid

• Never delay acute treatment: Efficacy of anti-inflammatory therapy decreases significantly if not started within 24 hours of symptom onset. 1, 3
• Never stop ULT during a flare: This is a common error that perpetuates disease activity. 1, 4
• Never start ULT without prophylaxis: Mobilization of urate crystals will trigger flares and lead to treatment abandonment. 1, 2
• Never use high-dose colchicine: The old regimen (1 mg every 1-2 hours until diarrhea) is obsolete and dangerous. 1, 2
• Never undertitrate allopurinol: Most treatment failures result from inadequate dosing, not true drug failure. 1
• Never treat asymptomatic hyperuricemia: Pharmacologic treatment is not recommended to prevent gout, renal disease, or cardiovascular events in asymptomatic patients. 1

Patient Education (Overarching Priority)

• Every patient must be fully informed about gout pathophysiology, the existence of effective treatments, the "treat-to-target" approach with lifelong serum uric acid lowering, and self-management of acute attacks. 1
• Full patient education increases adherence to ULT, achieving 92% treatment success at 12 months. 1
• Patients should be educated to self-medicate at first warning symptoms of a flare. 1