What are the treatment options for gout?

Treatment of Gout

For acute gout attacks, initiate treatment within 24 hours with NSAIDs, oral corticosteroids, or low-dose colchicine as equally appropriate first-line monotherapy options, selecting based on patient comorbidities and contraindications. 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
• Educate patients to self-initiate treatment at first warning symptoms without needing to contact their provider for each attack 1

First-Line Monotherapy Options (Mild-Moderate Attacks: 1-3 Small Joints or 1-2 Large Joints)

NSAIDs:

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 1
• Continue at full dose until the attack completely resolves 1
• Avoid in patients with chronic kidney disease (CKD), congestive heart failure, peptic ulcer disease, or cirrhosis 1
• Add proton pump inhibitor for gastroprotection where indicated 1

Oral Corticosteroids:

• Prednisone 0.5 mg/kg per day (or 30-35 mg/day) for 5-10 days at full dose, then stop OR taper over 7-10 days 1
• Equally effective as NSAIDs with similar safety profile 1
• Avoid in patients with diabetes, active infection, or high infection risk 1

Low-Dose Colchicine:

• 1.2 mg followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours), then may continue 0.6 mg twice daily starting at least 12 hours later until attack resolves 1
• Most effective when started within 12 hours of symptom onset; can be used up to 36 hours 1, 2
• Low-dose regimen has equal efficacy to high-dose with significantly fewer gastrointestinal side effects 2, 3
• Adjust dose for renal impairment and drug interactions (particularly with P-glycoprotein/CYP3A4 inhibitors like clarithromycin, cyclosporine) 1, 4
• For severe renal impairment (CrCl <30 mL/min) or dialysis patients: single 0.6 mg dose only, do not repeat more than once every 2 weeks 4

Combination Therapy (Severe/Polyarticular Attacks: ≥4 Joints or Severe Pain)

Appropriate combinations include: 1

• Colchicine + NSAIDs at full doses
• Oral corticosteroids + colchicine
• Intra-articular corticosteroids + any oral agent
• Do NOT combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Special Populations

NPO (Nothing by Mouth) Patients: 1

• Intra-articular corticosteroid injection for 1-2 accessible joints (dose varies by joint size)
• Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg
• Subcutaneous ACTH 25-40 IU with repeat doses as needed

Single Joint Involvement:

• Intra-articular corticosteroid injection is highly effective 1, 2

Inadequate Response Definition

• <20% improvement in pain within 24 hours OR <50% improvement after 24 hours 1
• Switch to another monotherapy or add a second appropriate agent 1

Adjunctive Measures

• Topical ice application to affected joint 1, 2

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate ULT in patients with: 1, 2, 3

• Recurrent acute gout attacks (≥2 per year)
• Tophi (palpable or on imaging)
• Chronic gouty arthropathy
• Radiographic changes of gout
• History of urolithiasis

Target Serum Urate

• <6 mg/dL (357 μmol/L) 1, 2, 5, 3

First-Line ULT Agents

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options 1, 2, 5, 3
• Start allopurinol at ≤100 mg/day (50 mg/day if CKD stage 4 or worse), titrate gradually to achieve target 5
• Uricosuric agents (probenecid, benzbromarone) are alternatives in patients with normal renal function and no urolithiasis history 1, 3

Anti-Inflammatory Prophylaxis During ULT Initiation

Mandatory Prophylaxis

All patients starting ULT must receive anti-inflammatory prophylaxis to prevent acute flares 1, 2, 5

First-Line Prophylaxis Options

Low-Dose Colchicine (Preferred):

• 0.5-0.6 mg once or twice daily 1, 2
• Adjust for renal impairment: 0.3 mg/day for severe CKD or dialysis 1, 4
• Adjust for drug interactions with P-glycoprotein/CYP3A4 inhibitors 1, 4

Low-Dose NSAIDs (Alternative):

• Naproxen 250 mg twice daily with proton pump inhibitor if indicated 1, 2

Low-Dose Prednisone (Second-Line):

• <10 mg/day if colchicine and NSAIDs are contraindicated or not tolerated 1, 2
• Doses >10 mg/day are inappropriate for prophylaxis 1

Duration of Prophylaxis

Continue prophylaxis for the GREATER of: 1, 2, 5

• At least 6 months after starting ULT, OR
• 3 months after achieving target serum urate (<6 mg/dL) in patients without tophi, OR
• 6 months after achieving target serum urate AND resolution of tophi in patients with tophi

Non-Pharmacologic Measures

• Weight loss for obese patients 1, 2, 3
• Avoid alcoholic drinks (especially beer and spirits) 1, 2, 3
• Avoid beverages sweetened with high-fructose corn syrup 2, 6
• Limit purine-rich foods (organ meats, shellfish) 6
• Encourage low-fat dairy products and vegetables 6
• Consider discontinuing diuretics if medically feasible 1

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2, 3
• Never stop ULT during acute attacks—this worsens disease control 1, 2
• Failure to provide prophylaxis when starting ULT leads to acute flares and poor adherence 1, 2, 3
• High-dose colchicine regimens (>1.8 mg in 12 hours) cause severe gastrointestinal toxicity without additional benefit 2, 3
• NSAIDs are contraindicated in heart failure, significant renal disease, and peptic ulcer disease 1, 2
• Colchicine drug interactions can cause life-threatening toxicity—always check for P-glycoprotein/CYP3A4 inhibitors 1, 3, 4
• Inadequate prophylaxis duration (<6 months) results in breakthrough flares 1, 3