From the Guidelines
Gout treatment should prioritize corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine for acute attacks, and urate-lowering therapy with allopurinol or febuxostat for long-term management in patients with frequent attacks or complications. When managing acute gout, the goal is to reduce inflammation and alleviate pain. According to the American College of Physicians guideline from 2017 1, corticosteroids, NSAIDs, or colchicine are recommended for treating acute gout, with a strong recommendation and high-quality evidence. For long-term management, the 2020 American College of Rheumatology guideline 1 provides strong recommendations for the use of urate-lowering therapy (ULT) in patients with tophaceous gout, radiographic damage, or frequent gout flares. Allopurinol is preferred as the first-line ULT, including for those with moderate to severe chronic kidney disease, with a starting dose of ≤100 mg/day. Key points for gout management include:
- Using colchicine at a low dose when treating acute gout, as recommended by the American College of Physicians 1
- Initiating ULT for patients with indications such as tophaceous gout or frequent flares, with a treat-to-target approach aiming for serum urate levels <6 mg/dL, as per the American College of Rheumatology guideline 1
- Implementing lifestyle modifications, including dietary changes, weight management, and hydration, to reduce the risk of gout attacks
- Considering concomitant anti-inflammatory prophylaxis for at least 3-6 months when starting ULT to prevent gout flares.
From the FDA Drug Label
For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine However, in patients with severe impairment, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks. For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet). For these patients, the treatment course should not be repeated more than once every two weeks [see Dosage and Administration (2. 5)] .
Gout Treatment:
- The recommended dose of colchicine for treatment of gout flares does not require adjustment in patients with mild to moderate renal impairment, but close monitoring for adverse effects is necessary.
- In patients with severe renal impairment, the treatment course should not be repeated more than once every two weeks.
- For patients undergoing dialysis, the recommended dose is a single dose of 0.6 mg, and the treatment course should not be repeated more than once every two weeks 2.
From the Research
Gout Treatment Overview
Gout is a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within the synovium of joints, leading to severe pain and reduced quality of life for patients with this condition 3.
Treatment Options for Acute Gout
- Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout, with equal efficacy, and the choice is guided by comorbidities 4, 5.
- IL-1 inhibitors, such as canakinumab, are effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 5, 6.
- Low-certainty evidence suggests that NSAIDs may improve pain at 24 hours and may have little to no effect on function, inflammation, or adverse events for treatment of acute gout 7.
Urate-Lowering Therapies
- Allopurinol and febuxostat are effective treatments for reducing concentrations of uric acid, with allopurinol being an agent of first choice for urate lowering therapy 3, 4, 6.
- Uricosuric agents, such as probenecid, increase uric acid excretion and are used as adjuncts to allopurinol and febuxostat 3, 4.
- Novel uricosurics, such as verinurad and arhalofenate, are emerging therapies with future promise 6.
Personalization of Treatment
- There is increasing personalization of treatment, adjusting pharmacotherapy depending on comorbidities, such as chronic kidney disease and ischemic heart disease, as well as patient preference 3, 6.
- Screening for HLA*B58:01 mutation is a cost-effective approach to decrease the occurrence of allopurinol hypersensitivity syndrome in Southeast Asian and Black populations 6.