What is the treatment for gout?

Treatment of Gout

For acute gout attacks, initiate NSAIDs, low-dose colchicine, or corticosteroids within 24 hours of symptom onset, and for patients with recurrent attacks, tophi, or chronic gouty arthropathy, start urate-lowering therapy with allopurinol or febuxostat while maintaining anti-inflammatory prophylaxis for at least 6 months. 1, 2

Acute Gout Attack Management

First-Line Treatment Options (Choose Based on Patient Factors)

NSAIDs at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) should be started immediately and continued until complete resolution of the attack. 1, 2 The specific NSAID chosen matters less than how quickly treatment begins—delaying beyond 24 hours significantly reduces effectiveness. 1, 3

Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is equally effective as high-dose regimens but with substantially fewer gastrointestinal side effects when started within 36 hours of symptom onset. 1, 2 This low-dose approach avoids the significant adverse effects of traditional high-dose colchicine regimens. 2, 3

Oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days, or 30-35 mg/day prednisolone equivalent for 3-5 days) are particularly valuable for patients with contraindications to NSAIDs or colchicine. 1, 2, 3

Intra-articular corticosteroid injection is highly effective when only a single joint is involved. 1, 2, 3

Treatment Algorithm Based on Disease Severity

For mild attacks (1-3 small joints or 1-2 large joints): Use monotherapy with any of the above first-line options. 1, 3

For severe attacks (pain ≥7/10 or ≥4 joints involved): Use combination therapy such as colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality. 1, 2

For patients who cannot take oral medications: Use intra-articular corticosteroid injection for 1-2 affected joints, or intravenous/intramuscular methylprednisolone (0.5-2.0 mg/kg) for multiple joint involvement. 2

Special Population Considerations

Patients with renal impairment: Corticosteroids are safer than NSAIDs or colchicine. 2 For severe renal impairment (CrCl <30 mL/min), colchicine dose should be reduced to a single 0.6 mg dose, with treatment courses repeated no more than once every two weeks. 4

Patients with heart failure, peptic ulcer disease, or significant renal disease: Avoid NSAIDs entirely. 1, 2, 3

Patients on dialysis: Use a single 0.6 mg colchicine dose, repeated no more than once every two weeks. 4

Managing Inadequate Response

Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours. 1, 2 Switch to another monotherapy or add a second agent if initial treatment fails. 2

Adjunctive Measures

Apply topical ice to the affected joint during acute attacks. 1, 2, 3 Educate patients to self-initiate treatment at the first warning symptoms using a "pill in the pocket" approach. 2, 3

Long-Term Urate-Lowering Therapy (ULT)

Indications for Starting ULT

Initiate urate-lowering therapy for patients with:

• Recurrent acute attacks (more than one per year) 1, 2, 3
• Tophi (visible or radiographic) 1, 2, 3
• Chronic gouty arthropathy 1, 3
• Radiographic changes of gout 1, 2

Do NOT initiate ULT after a first gout attack or in patients with infrequent attacks. 2

First-Line ULT Agents

Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options. 1, 2, 3 Start allopurinol at no more than 100 mg/day and gradually titrate upward every 2-5 weeks to reach target serum urate. 3 Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with CKD, Han Chinese, or Thai patients). 3

Uricosuric agents (probenecid or benzbromarone) are alternatives for patients with normal renal function, no history of urolithiasis, and who cannot tolerate xanthine oxidase inhibitors. 2, 3

Target Serum Urate Level

Maintain serum urate below 6 mg/dL. 1, 2, 3 This level is essential for dissolving monosodium urate crystals and preventing future attacks.

Critical Principle: Continue ULT During Acute Attacks

Never discontinue established urate-lowering therapy during an acute gout attack—doing so worsens outcomes. 1, 2, 3 Research demonstrates that initiating allopurinol during an acute attack does not prolong the attack when appropriate anti-inflammatory therapy is used. 5

Anti-Inflammatory Prophylaxis During ULT Initiation

Mandatory Prophylaxis

Anti-inflammatory prophylaxis is mandatory when starting urate-lowering therapy to prevent acute flares that commonly occur during the initial months of treatment. 1, 2, 3 Failure to provide prophylaxis leads to breakthrough flares and poor medication adherence. 1, 3

Prophylaxis Options

First-line prophylactic agents:

• Low-dose colchicine (0.5-0.6 mg once or twice daily) 1, 2, 3
• Low-dose NSAIDs with gastroprotection if indicated 1, 2, 3
• Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1, 2

Duration of Prophylaxis

Continue prophylaxis for the greater of:

• At least 6 months, OR 1, 2, 3
• 3 months after achieving target serum urate if no tophi are present, OR 1, 2, 3
• 6 months after achieving target serum urate if tophi were present 1, 2, 3

Non-Pharmacologic Measures

Weight loss is recommended for obese patients. 1, 2, 3

Dietary modifications:

• Avoid alcoholic drinks, especially beer 1, 2, 3
• Avoid beverages sweetened with high-fructose corn syrup 1, 2, 3
• Limit purine-rich foods (organ meats, shellfish) 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products 6

Medication review: Loop and thiazide diuretics increase uric acid levels, while losartan increases urinary uric acid excretion. 6

Critical Pitfalls to Avoid

Delaying acute treatment beyond 24 hours dramatically reduces effectiveness—early initiation is the most important determinant of therapeutic success. 1, 2, 3

Using high-dose colchicine regimens causes significant gastrointestinal toxicity without additional benefit compared to low-dose regimens. 2, 3

Discontinuing ULT during acute flares worsens outcomes and should never be done. 1, 2, 3

Failing to provide prophylaxis when starting ULT leads to acute flares and treatment abandonment. 1, 3

Drug interactions with colchicine must be carefully considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporine, clarithromycin), which can cause serious colchicine toxicity. 2, 4

Treating gout flares with colchicine in patients with renal or hepatic impairment who are already receiving colchicine for prophylaxis is not recommended. 4