What are the best strategies for preventing gout?

Gout Prevention Strategies

The most effective gout prevention combines mandatory lifestyle modifications with early initiation of urate-lowering therapy (allopurinol starting at 100 mg daily, titrated to achieve serum uric acid <6 mg/dL) in patients with recurrent attacks, plus comprehensive management of associated comorbidities. 1

Patient Education: The Foundation of Prevention

Every person with gout must receive comprehensive education about the disease pathophysiology, the existence of effective treatments, associated comorbidities, and the principles of lifelong serum uric acid lowering below target levels. 1 Education is critical because observational studies demonstrate that full patient education increases adherence to urate-lowering therapy, achieving a 92% treatment success rate at 12 months. 1

Lifestyle Modifications: Non-Negotiable First Steps

Weight Management

• Weight loss is essential for overweight/obese patients, achieved through daily exercise and limiting excess calorie intake. 1, 2
• Weight reduction >5% BMI is associated with 40% lower odds of recurrent gout flares. 2
• Regular physical activity decreases the excess mortality associated with chronic hyperuricemia. 1

Dietary Restrictions

Foods to Avoid or Limit:

• Alcohol, especially beer and spirits, must be avoided or severely restricted as they increase uric acid through adenine nucleotide degradation and lactate production. 1, 2
• Complete alcohol abstinence is recommended during active gout arthritis when medical control is inadequate. 2
• Sugar-sweetened beverages and foods rich in high-fructose corn syrup should be eliminated as they raise uric acid levels. 1, 2
• Purine-rich meats and seafood (especially organ meats and shellfish) must be limited. 1, 2
• Heavy meals should be avoided. 1

Foods to Encourage:

• Low-fat dairy products (particularly skim milk and low-calorie yogurt) should be consumed regularly as they have antihyperuricemic effects. 1, 2
• Cherries may reduce serum urate levels and frequency of gout attacks. 1, 2
• Coffee consumption is negatively associated with gout risk. 1

Critical Caveat About Diet

Diet and lifestyle measures alone typically provide only 10-18% decrease in serum urate levels, which is insufficient for most patients with significantly elevated uric acid. 2 Therefore, dietary modifications must be combined with pharmacological urate-lowering therapy for optimal prevention. 2

Pharmacological Prevention: Urate-Lowering Therapy (ULT)

Indications for ULT

Urate-lowering therapy is indicated in patients with: 1

• Recurrent acute gout attacks
• Arthropathy from gout
• Tophi (visible or radiographic)
• Radiographic changes of gout
• Chronic kidney disease associated with gout

Target Serum Uric Acid Level

The therapeutic goal is maintaining serum uric acid <6 mg/dL (360 μmol/L) lifelong to promote crystal dissolution and prevent crystal formation. 1 This target should be maintained indefinitely. 1

First-Line ULT: Allopurinol

Allopurinol is the recommended first-line urate-lowering drug in patients with normal kidney function. 1, 3

Dosing Algorithm: 1, 3

• Start at 100 mg daily
• Increase by 100 mg increments every 2-4 weeks as needed
• Titrate until serum uric acid target <6 mg/dL is achieved
• Maximum recommended dose is 800 mg daily
• Normal serum urate levels are usually achieved in 1-3 weeks

Renal Dose Adjustments: 1, 3

• Creatinine clearance 10-20 mL/min: maximum 200 mg daily
• Creatinine clearance <10 mL/min: maximum 100 mg daily
• Creatinine clearance <3 mL/min: may need to lengthen interval between doses

Alternative ULT Options

If the serum uric acid target cannot be reached with appropriate allopurinol dosing, or if allopurinol cannot be tolerated: 1

• Switch to febuxostat
• Switch to a uricosuric agent (probenecid, benzbromarone)
• Combine allopurinol with a uricosuric agent

Mandatory Flare Prophylaxis During ULT Initiation

When starting urate-lowering therapy, prophylaxis against acute flares is required for the first 6 months (or longer if tophi present). 1, 4

Prophylaxis Options: 1, 5

• Colchicine 0.5-1 mg daily (preferred)
• NSAID with gastroprotection if appropriate
• Low-dose corticosteroids if other options contraindicated

Colchicine Dose Adjustments for Prophylaxis: 5

• Creatinine clearance 30-50 mL/min: reduce to 0.5 mg daily or every other day
• Severe renal impairment: start at 0.3 mg daily
• Dialysis patients: 0.3 mg twice weekly

Critical Pitfall to Avoid

Never discontinue prophylaxis prematurely. Prophylaxis should continue for at least 3 months after serum uric acid reaches target in patients without tophi, and 6 months in those with history of tophi. 1

Management of Associated Comorbidities

Every person with gout must be systematically screened for associated comorbidities, as these should be addressed as an integral part of gout prevention. 1

Medication Adjustments for Comorbidities

When gout occurs in patients receiving diuretics: 1, 4

• Discontinue loop or thiazide diuretics if possible (most common iatrogenic cause of gout)
• For hypertension: switch to losartan (has modest uricosuric effects) or calcium channel blockers
• For hyperlipidemia: consider fenofibrate (has uricosuric properties) or statins

Comorbidities to Screen and Manage: 1

• Chronic kidney disease (calculate eGFR at diagnosis and monitor regularly)
• Coronary heart disease
• Heart failure
• Stroke and peripheral arterial disease
• Obesity
• Hyperlipidemia
• Hypertension
• Diabetes
• Smoking cessation

Algorithmic Approach to Gout Prevention

Step 1: Provide comprehensive patient education about gout pathophysiology and lifelong management. 1

Step 2: Implement mandatory lifestyle modifications (weight loss if obese, alcohol avoidance, dietary changes, regular exercise). 1, 2

Step 3: Screen for and aggressively manage all associated comorbidities; adjust medications that raise uric acid. 1, 4

Step 4: For patients with recurrent attacks, tophi, or radiographic changes, initiate allopurinol 100 mg daily with concurrent flare prophylaxis (colchicine 0.5-1 mg daily). 1, 4, 3

Step 5: Titrate allopurinol by 100 mg every 2-4 weeks until serum uric acid <6 mg/dL is achieved and maintained. 1, 3

Step 6: Continue flare prophylaxis for minimum 6 months after reaching target serum uric acid. 1, 4

Step 7: Monitor serum uric acid lifelong to maintain target <6 mg/dL indefinitely. 1