What are the management options for gout joints after consulting a rheumatologist?

Management of Gout Following Rheumatology Consultation

After seeing a rheumatologist for gout, initiate urate-lowering therapy with allopurinol 100 mg daily, titrate every 2-4 weeks to achieve serum uric acid <6 mg/dL, and provide mandatory anti-inflammatory prophylaxis for at least 6 months to prevent flares during treatment. 1

Immediate Initiation of Urate-Lowering Therapy

Start allopurinol as first-line therapy regardless of current flare status. 1

• Begin with allopurinol 100 mg daily (or lower if chronic kidney disease stage >3 is present) 1, 2
• Titrate upward by 100 mg increments every 2-4 weeks until target serum uric acid is achieved 1, 2
• Maximum dose is 800 mg daily in patients with normal renal function 1, 2
• For patients with creatinine clearance 10-20 mL/min, use 200 mg daily maximum 2
• For creatinine clearance <10 mL/min, do not exceed 100 mg daily 2

The 2020 ACR guidelines strongly recommend allopurinol over febuxostat as first-line therapy, including in patients with moderate-to-severe chronic kidney disease. 1 This represents a shift from earlier practice patterns and is based on cardiovascular safety concerns with febuxostat. 3

Target Serum Uric Acid Levels

Achieve and maintain serum uric acid <6 mg/dL as the primary target. 1, 2

• For patients with tophi or erosive arthropathy, consider a more intensive target of <5 mg/dL to facilitate faster crystal dissolution 4
• Check serum uric acid every 2-4 weeks during dose titration 4
• Once stable on maintenance therapy, monitor every 6 months 4

The treat-to-target strategy is a strong recommendation based on the principle that sustained reduction in serum urate prevents flares and allows resolution of tophi. 1

Mandatory Anti-Inflammatory Prophylaxis

Begin prophylaxis with or just prior to initiating urate-lowering therapy and continue for at least 6 months. 1, 4

First-line prophylaxis options include: 1

• Low-dose colchicine 0.6 mg daily 1, 5
• Low-dose NSAIDs with proton pump inhibitor when gastrointestinal risk factors present 1, 5
• Low-dose prednisone/prednisolone (<10 mg daily) if colchicine and NSAIDs contraindicated 1, 6

Continue prophylaxis until: 4

• At least 6 months have passed, AND
• Serum uric acid target has been achieved, AND
• Patient has been free of flares for several months 2

A critical pitfall is failing to provide prophylaxis when starting urate-lowering therapy—this leads to increased flare frequency during the initial months as urate crystals mobilize from tissue deposits. 2 The FDA label for allopurinol explicitly warns that acute gout attacks increase during early therapy even when serum uric acid normalizes. 2

Management of Acute Flares During Treatment

Never discontinue urate-lowering therapy during an acute flare. 4, 5

Treat acute flares promptly with one of the following: 1

• NSAIDs at full anti-inflammatory doses 1
• Low-dose colchicine: 1.2 mg followed by 0.6 mg one hour later 5
• Oral corticosteroids: prednisone 30-35 mg daily for 3-5 days 6
• Intra-articular corticosteroid injection for monoarticular involvement (triamcinolone acetonide 40 mg for large joints) 6

Initiate treatment within 24 hours of symptom onset for optimal outcomes. 6 Stopping urate-lowering therapy during acute attacks worsens and prolongs the attack. 5

Alternative Urate-Lowering Therapy Options

If target serum uric acid is not achieved with appropriate allopurinol dosing or if allopurinol is not tolerated: 4

• Switch to febuxostat (start <40 mg daily, titrate as needed) 1
• Add a uricosuric agent such as probenecid (contraindicated if creatinine clearance <50 mL/min) 1, 7
• Consider lesinurad as add-on therapy to xanthine oxidase inhibitors 8

The 2020 guidelines note that febuxostat carries cardiovascular mortality concerns, making it a second-line option rather than equivalent to allopurinol. 1, 3

Lifestyle Modifications

Implement dietary and lifestyle changes as adjunctive therapy: 4

• Weight loss if overweight or obese 4
• Avoid alcohol, especially beer, and sugar-sweetened beverages 4, 9
• Limit excessive intake of meat and seafood 4, 9
• Encourage low-fat or nonfat dairy products 4, 9
• Regular exercise 4

Medication Review and Comorbidity Management

Review and modify medications that increase uric acid: 4

• Substitute loop or thiazide diuretics if clinically appropriate 4
• Consider losartan or calcium channel blockers for hypertension management 4, 9
• Consider statin or fenofibrate for hyperlipidemia 4

Monitoring Protocol

Establish a systematic monitoring schedule: 4, 2

• Serum uric acid every 2-4 weeks during titration 4
• Serum uric acid every 6 months once stable 4
• Renal function (BUN, creatinine) periodically, especially in patients with pre-existing renal disease or concurrent conditions affecting renal function 2
• Liver function tests in patients with pre-existing liver disease during early therapy 2

Fluid Intake Requirements

Maintain adequate hydration to prevent complications: 2

• Ensure daily urinary output of at least 2 liters 2
• Maintain neutral or slightly alkaline urine pH 2
• This prevents xanthine calculi formation and helps prevent renal precipitation of urates 2

Long-Term Continuation

Continue urate-lowering therapy indefinitely to maintain serum uric acid <6 mg/dL. 1

After tophi and all acute and chronic gouty arthritis symptoms have resolved, continue all measures including pharmacologic urate-lowering therapy to maintain target serum urate levels lifelong. 1 Gout is a chronic disease requiring ongoing management, not episodic treatment of flares alone. 10