What is the recommended treatment plan for gout?

Gout Treatment Plan

For acute gout attacks, initiate treatment within 24 hours with NSAIDs, low-dose colchicine, or corticosteroids as first-line monotherapy, and for long-term management, start urate-lowering therapy (allopurinol preferred) in all patients with recurrent attacks, tophi, or radiographic damage, with a target serum urate below 6 mg/dL. 1

Acute Gout Attack Management

Timing and General Approach

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes. 1, 2
• Continue established urate-lowering therapy without interruption during acute attacks—do not stop ULT. 1, 2, 3
• Apply topical ice as an adjunctive measure during acute attacks. 1, 2, 3

First-Line Pharmacologic Options (Monotherapy)

For mild-to-moderate attacks (pain ≤6/10 on VAS) involving 1-3 small joints or 1-2 large joints, choose one of the following based on patient comorbidities: 1

NSAIDs

• Use full anti-inflammatory doses when started promptly. 1, 4
• Avoid in patients with chronic kidney disease stage ≥3, congestive heart failure, peptic ulcer disease, or cirrhosis. 2, 4, 3

Low-Dose Colchicine

• Dose: 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg). 1, 4, 3
• Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours. 4
• Low-dose colchicine is equally effective as high-dose regimens but with significantly fewer gastrointestinal side effects. 2, 3
• Adjust dose for renal impairment and drug interactions with CYP3A4 inhibitors. 5

Corticosteroids

• Oral prednisone: 30-35 mg/day for 3-5 days or 0.5 mg/kg/day for 5-10 days. 4, 3
• Intra-articular corticosteroid injection is appropriate for 1-2 accessible affected joints. 1, 4, 3
• Avoid in patients with diabetes, active infection, or high infection risk. 4

Combination Therapy

• For severe pain (>6/10 on VAS) in polyarticular attacks, combination therapy with two of the above agents is appropriate. 1, 4

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate ULT in patients with: 1, 2

• Recurrent acute gout attacks (≥2 per year)
• Tophaceous gout
• Chronic gouty arthropathy
• Radiographic damage due to gout
• History of nephrolithiasis

First-Line ULT: Allopurinol

• Allopurinol is the preferred first-line agent, including for patients with moderate-to-severe chronic kidney disease (stage ≥3). 1
• Starting dose: ≤100 mg/day (50 mg/day in CKD stage ≥4). 1, 4
• 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, Thai). 3

Alternative ULT Options

• Febuxostat: Starting dose <40 mg/day. 1
• Uricosuric agents (probenecid, benzbromarone) are alternatives when xanthine oxidase inhibitors cannot be used, but require normal renal function and no history of urolithiasis. 1, 3

Target Serum Urate

• Target serum urate: <6 mg/dL for all patients. 1, 2, 4
• Target <5 mg/dL for patients with tophi. 2
• Use a treat-to-target strategy with ULT dose titration guided by serial serum urate measurements. 1

Anti-Inflammatory Prophylaxis During ULT Initiation

Rationale and Timing

• Initiate anti-inflammatory prophylaxis with or just before starting ULT to prevent acute flares. 1, 4, 3
• Failure to provide prophylaxis often leads to acute flares and poor medication adherence. 2, 3

Prophylaxis Options

First-line: 1, 4, 3

• Low-dose colchicine: 0.5-0.6 mg once or twice daily (adjust for renal function and drug interactions)
• Low-dose NSAIDs with gastroprotection if indicated
• Low-dose prednisone (≤10 mg/day) for patients with contraindications to both colchicine and NSAIDs

Duration of Prophylaxis

• Continue for at least 6 months, OR 3 months after achieving target serum urate in patients without tophi. 1, 4, 3
• For patients with tophi, continue for 6 months after achieving target serum urate and resolution of tophi. 4, 3

Lifestyle Modifications

Patient education is a core aspect of management: 1, 2

• Weight loss for obese patients 1, 4, 3
• Avoid alcohol (especially beer and spirits) and beverages sweetened with high-fructose corn syrup. 2, 4, 3
• Avoid purine-rich foods (organ meats, shellfish). 2, 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products. 2, 6
• Educate patients to self-initiate treatment upon first signs of an acute attack without needing to consult their healthcare provider each time. 1, 3

Medication Adjustments for Comorbidities

Diuretic-Associated Gout

• Stop the diuretic if possible. 1
• For hypertension, consider losartan (modest uricosuric effect). 1
• For hyperlipidemia, consider fenofibrate (modest uricosuric effect). 1

Renal Impairment Dosing

For prophylaxis: 5

• Mild-moderate impairment (CrCl 30-80 mL/min): No dose adjustment required, but monitor closely
• Severe impairment (CrCl <30 mL/min): Start colchicine at 0.3 mg/day
• Dialysis: Start colchicine at 0.3 mg twice weekly

For acute treatment: 5

• Mild-moderate impairment: No dose adjustment, but monitor closely
• Severe impairment: Treatment course should not be repeated more than once every two weeks
• Dialysis: Single dose of 0.6 mg, not repeated more than once every two weeks

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness. 2, 3
• Discontinuing ULT during acute attacks worsens outcomes—always continue established ULT. 1, 2, 3
• Using high-dose colchicine regimens causes significant gastrointestinal toxicity without additional benefit. 2, 3
• Starting ULT without prophylaxis leads to acute flares and treatment abandonment. 2, 3
• Prescribing NSAIDs to patients with heart failure, peptic ulcer disease, or significant renal disease. 3