From the Guidelines
Gout should be managed with a combination of pharmacologic and nonpharmacologic approaches, focusing on urate-lowering strategies, anti-inflammatory drugs, and lifestyle modifications to prevent joint damage and other complications of chronic gout. The diagnosis of gout involves a combination of clinical symptoms, blood tests, and joint fluid analysis, with the hallmark being elevated uric acid levels in the blood (hyperuricemia) and the presence of monosodium urate crystals in joint fluid 1.
Treatment Options
For acute gout attacks, the following treatment options are recommended:
- NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily) are first-line treatments, typically given for 3-5 days 1.
- Colchicine is also effective when started early (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve) 1.
- Corticosteroids like prednisone (30-40mg daily for 3-5 days, then tapered) can be used for patients who can't take NSAIDs or colchicine 1.
Long-term Management
For long-term management, urate-lowering therapy is recommended for patients with frequent attacks or complications. The following options are available:
- Allopurinol (starting at 100mg daily, gradually increasing to 300-600mg daily) or febuxostat (40-80mg daily) reduce uric acid production 1.
- Probenecid (250mg twice daily, increasing to 500mg twice daily) increases uric acid excretion 1.
- The target is to maintain serum uric acid below 6mg/dL 1.
Lifestyle Modifications
Lifestyle modifications are also important, including:
- Weight loss if overweight 1.
- Limiting alcohol (especially beer) 1.
- Avoiding high-purine foods like organ meats and shellfish 1.
- Staying well-hydrated 1.
Key Recommendations
The American College of Physicians (ACP) recommends against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks 1. However, urate-lowering therapy should be considered from the first presentation of the disease, and serum uric acid levels should be maintained at <6 mg/dL (360 mmol/L) and <5 mg/dL (300 mmol/L) in those with severe gout 1. Clinicians should discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks 1.
From the FDA Drug Label
General An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets, even when normal or subnormal serum uric acid levels have been attained. The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis.
The diagnosis of gout is not directly addressed in the provided drug labels. For the treatment of gout, options include:
- Allopurinol: to reduce serum uric acid levels, with a recommended starting dose of 100 mg daily and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained.
- Colchicine: to suppress gouty attacks, generally given prophylactically when allopurinol is begun.
- Probenecid: to treat hyperuricemia associated with gout and gouty arthritis.
- Anti-inflammatory agents: may be required to suppress gouty attacks in some cases 2, 2, 3.
From the Research
Diagnosis of Gout
- Gout is characterized by painful joint inflammation, most commonly in the first metatarsophalangeal joint, resulting from precipitation of monosodium urate crystals in a joint space 4
- Diagnosis may be confirmed by identification of monosodium urate crystals in synovial fluid of the affected joint 4
- Diagnosis of gout can be made using several validated clinical prediction rules, and arthrocentesis should be performed when suspicion for an underlying septic joint is present 5
Treatment Options for Acute Gout
- Nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are options for the management of acute gout 4, 6, 5
- 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
- Moderate-certainty evidence shows that COXIBs and non-selective NSAIDs are probably equally beneficial with regards to improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs probably increase withdrawals due to adverse events and total adverse events 7
Prevention of Recurrent Gout Flares
- To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods (e.g., organ meats, shellfish) and avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 4
- Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout, and colchicine and/or probenecid are reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective 4, 6, 8
- Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 5
Urate-Lowering Therapy
- Allopurinol is an effective treatment for reducing concentrations of uric acid, and renal function guides the starting dose of allopurinol and the baseline serum uric acid concentration guides the maintenance dose 6
- Febuxostat is another xanthine oxidase inhibitor, and it is clinically equivalent to allopurinol 6, 8
- Uricosuric drugs, such as probenecid, increase uric acid excretion, and new drugs in this class will soon become available and are likely to have a role in the treatment of patients who do not respond to other drugs 6, 8