What is the treatment protocol for gout?

Gout Treatment Protocol

For acute gout attacks, initiate treatment within 24 hours using NSAIDs, low-dose colchicine, or corticosteroids as first-line monotherapy, selecting based on comorbidities; for long-term management, start urate-lowering therapy after recurrent attacks with mandatory anti-inflammatory prophylaxis to prevent flares. 1, 2

Acute Gout Attack Management

First-Line Monotherapy Options (for 1-3 small joints or 1-2 large joints)

Treatment must be initiated within 24 hours of symptom onset for optimal effectiveness 2, 3:

• NSAIDs at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) should be started promptly and continued until complete resolution 2

  • Avoid in patients with chronic kidney disease, congestive heart failure, peptic ulcer disease, or cirrhosis 1, 2

• Low-dose colchicine: 1.2 mg followed by 0.6 mg one hour later 1, 2

  • Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 2
  • Equally effective as high-dose regimens with significantly fewer gastrointestinal side effects 4
  • Adjust dose for renal impairment: in severe renal failure (CrCl <30 mL/min), use single 0.6 mg dose and do not repeat course more than once every two weeks 5

• Oral corticosteroids: Prednisone 30-35 mg/day for 3-5 days or 0.5 mg/kg/day for 5-10 days 1, 2

  • Particularly useful for patients with contraindications to NSAIDs or colchicine 2
  • Avoid in patients with diabetes, active infection, or high infection risk 1

• Intra-articular corticosteroid injection for 1-2 accessible affected joints 1, 2

  • Highly effective for single joint involvement 2

Combination Therapy

• For severe pain or polyarticular involvement (≥4 joints), use combination therapy 2, 3

Adjunctive Measures

• Apply topical ice to affected joints 2, 3
• Continue established urate-lowering therapy without interruption during acute attacks 2, 3

Monitoring Treatment Response

• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours of starting therapy 2

Long-Term Urate-Lowering Therapy (ULT)

Indications for Initiating ULT

Start ULT in patients with: 1, 2, 3

• Recurrent acute attacks (≥2 per year)
• Tophi
• Chronic gouty arthropathy
• Radiographic changes of gout
• History of nephrolithiasis

First-Line ULT Options

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line agents 1, 2, 3

• Allopurinol dosing: Start at ≤100 mg/day (50 mg/day in stage 4 or worse CKD) 1

  • Titrate gradually upward every 2-5 weeks to reach target serum urate 3
  • Consider HLA-B*5801 testing before initiating in high-risk populations (Koreans with CKD, Han Chinese, Thai) 3

• Target serum urate level: <6 mg/dL (357 μmol/L) 1, 2, 3

Alternative ULT Options

• Uricosuric agents (probenecid) are alternatives when xanthine oxidase inhibitors cannot be used 3

Mandatory Anti-Inflammatory Prophylaxis During ULT Initiation

Prophylaxis must be initiated with or just before starting ULT to prevent flares 1, 2, 3:

First-Line Prophylaxis Options

• Low-dose colchicine: 0.5-0.6 mg once or twice daily 1, 2, 3

  • Adjust for renal function and drug interactions 1

• Low-dose NSAIDs (e.g., naproxen) with proton pump inhibitor if indicated 1, 2

• Low-dose prednisone (≤10 mg/day) for patients with contraindications to both colchicine and NSAIDs 1, 2

Duration of Prophylaxis

Continue prophylaxis for: 1, 2, 3

• Minimum 6 months, OR
• 3 months after achieving target serum urate for patients without tophi, OR
• 6 months after achieving target serum urate AND resolution of tophi for patients with tophi

Lifestyle Modifications

• Weight loss for obese patients 1, 2, 3
• Avoid alcohol (especially beer and spirits) 1, 2, 3
• Avoid sugar-sweetened beverages and high-fructose corn syrup 1, 2, 3
• Limit purine-rich foods (organ meats, shellfish) 6
• Encourage consumption of vegetables and low-fat/nonfat dairy products 6

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
• Never discontinue ULT during acute attacks—this worsens outcomes 2, 3
• Failure to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 2, 3
• Do not use high-dose colchicine regimens—low-dose is equally effective with fewer gastrointestinal side effects 4, 3
• Treatment of gout flares with colchicine is not recommended in patients with renal or hepatic impairment who are already receiving colchicine for prophylaxis 5