What are the differences in acute and chronic management of gout and pseudogout?

Gout vs Pseudogout Management: Acute & Chronic Comparison

Acute Management

Gout - Acute Attack

For acute gout, choose between corticosteroids, NSAIDs, or colchicine as first-line therapy, with selection based on patient contraindications and cost considerations. 1

• NSAIDs are preferred for acute gout when no contraindications exist, with the critical factor being early initiation rather than which specific NSAID is selected 2
• Low-dose colchicine (1.5 mg total: 1.2 mg initially, then 0.6 mg one hour later) should be used instead of high-dose regimens to minimize gastrointestinal and other adverse effects 1
• Corticosteroids (oral, intravenous, or intra-articular) are equally effective alternatives, particularly useful in patients with renal insufficiency or contraindications to NSAIDs and colchicine 2
• Topical ice and rest of the inflamed joint provide useful adjunctive nonpharmacological support 2

Common pitfall: Starting treatment late reduces efficacy dramatically - immediate initiation at first symptom onset is essential 2

Pseudogout - Acute Attack

Pseudogout acute attacks are treated identically to gout: NSAIDs, colchicine, or corticosteroids. 2, 3

• The same three medication classes (NSAIDs, colchicine, corticosteroids) are used for acute pseudogout flares 3
• Intra-articular corticosteroid injection is particularly effective for monoarticular pseudogout 3
• No crystal-lowering therapy exists for pseudogout (unlike gout), so management focuses solely on inflammation control 3

Key difference: Pseudogout has no equivalent to urate-lowering therapy - you cannot prevent crystal formation 3

Chronic Management

Gout - Long-term/Recurrent Disease

Do not initiate urate-lowering therapy after a first gout attack or in patients with infrequent attacks; reserve it for recurrent disease. 1

When to Start Urate-Lowering Therapy:

• Initiate urate-lowering therapy (ULT) only in patients with recurrent attacks (≥2 per year), tophi, radiographic changes, or uric acid nephrolithiasis 4, 5
• Discuss benefits, harms, costs, and patient preferences before starting ULT 1

Urate-Lowering Therapy Protocol:

• Allopurinol is first-line therapy: Start at 100 mg daily and increase by 100 mg every 2-4 weeks until serum uric acid reaches <6 mg/dL, maximum 800 mg daily 4, 6
• Target serum uric acid <6 mg/dL (360 μmol/L) and maintain lifelong 4
• Febuxostat is second-line if allopurinol fails to achieve target or is not tolerated 4
• Uricosuric agents (probenecid) are third-line options 4

Flare Prophylaxis During ULT Initiation:

• Mandatory prophylaxis with colchicine or NSAIDs during the first months of urate-lowering therapy prevents paradoxical flares that occur from urate mobilization 7, 6
• Continue prophylaxis until serum uric acid is normalized and patient has been attack-free for several months 6

Critical pitfall: Starting ULT during an acute attack or without prophylaxis will trigger severe flares 6

Lifestyle Modifications:

• Weight loss (5% BMI reduction) reduces recurrent flare odds by 40% in overweight/obese patients 7
• Limit alcohol (especially beer and spirits), purine-rich foods (organ meats, shellfish), and high-fructose corn syrup beverages 7, 8
• Encourage low-fat dairy products which have protective effects 8
• Maintain fluid intake sufficient for ≥2 liters daily urinary output 6

Monitoring:

• Regular serum uric acid monitoring is essential to ensure target <6 mg/dL is maintained 7
• Adjust allopurinol dosing in renal impairment: creatinine clearance 10-20 mL/min = 200 mg daily; <10 mL/min = 100 mg daily maximum 6

Pseudogout - Long-term/Recurrent Disease

Pseudogout chronic management is fundamentally limited to symptom control and inflammation suppression - no disease-modifying therapy exists. 3

• Chronic pseudogout may present as polyarthropathy resembling osteoarthritis or rheumatoid arthritis, requiring ongoing anti-inflammatory therapy 3
• NSAIDs or low-dose colchicine can be used for chronic symptom control 3
• Consider prophylactic colchicine for patients with frequent recurrent attacks, though evidence is limited 2
• No dietary modifications or lifestyle changes affect calcium pyrophosphate crystal formation 3

Key difference: Unlike gout where you can deplete uric acid stores and prevent future attacks, pseudogout has no preventive therapy - management remains purely symptomatic 3

Critical Distinctions Summary

Feature	Gout	Pseudogout
Acute treatment	NSAIDs/colchicine/corticosteroids [1]	NSAIDs/colchicine/corticosteroids [3]
Chronic prevention	Urate-lowering therapy available [4]	No disease-modifying therapy [3]
Lifestyle impact	Significant (diet, alcohol, weight) [7]	Minimal to none [3]
Monitoring	Serum uric acid targets [7]	No biochemical monitoring needed [3]
Long-term prognosis	Controllable with ULT [7]	Recurrent attacks inevitable [3]

The fundamental management difference: Gout is a treatable metabolic disease where you can eliminate future attacks through urate-lowering therapy, while pseudogout remains a chronic condition requiring only symptomatic management without disease modification options. 4, 3