What is the standard treatment for gout?

Standard Treatment for Gout

For acute gout attacks, initiate treatment within 24 hours using monotherapy with NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or corticosteroids, with selection based on patient comorbidities and contraindications. 1, 2

Acute Gout Attack Management

Treatment Initiation and General Principles

• Begin pharmacologic therapy within 24 hours of symptom onset for optimal outcomes, as delayed treatment significantly reduces effectiveness 1, 2
• Continue established urate-lowering therapy without interruption during acute attacks—discontinuing ULT worsens outcomes 3, 1, 2
• Apply topical ice as an adjunctive measure during acute attacks 1, 2

First-Line Monotherapy Options (for mild-moderate attacks involving 1-3 small joints or 1-2 large joints)

NSAIDs:

• Use full anti-inflammatory doses (naproxen, indomethacin, or sulindac) and continue until the attack completely resolves 2
• Avoid in patients with heart failure, peptic ulcer disease, renal disease, or cirrhosis 1, 2

Low-Dose Colchicine:

• Dose: 1.2 mg followed by 0.6 mg one hour later when started within 36 hours of symptom onset 2, 4
• This low-dose regimen is equally effective as higher doses with significantly fewer gastrointestinal side effects 1, 2
• For severe renal impairment (CrCl <30 mL/min), reduce to single 0.6 mg dose and do not repeat more than once every two weeks 4

Corticosteroids:

• Oral prednisone 0.5 mg/kg per day for 5-10 days is particularly useful for patients with contraindications to NSAIDs or colchicine 2
• Intra-articular corticosteroid injection is highly effective for single accessible joint involvement 1, 2

Combination Therapy

• For severe pain (>6/10 on pain scale) or polyarticular involvement (≥4 joints), use combination therapy with agents from different classes 3, 2

Inadequate Response Definition

• Less than 20% improvement in pain within 24 hours, or less than 50% improvement after 24 hours of starting therapy warrants treatment adjustment 2

Long-Term Management of Chronic Gout

Indications for Urate-Lowering Therapy (ULT)

• Recurrent acute attacks (≥2 per year) 1, 2
• Presence of tophi 1, 2
• Chronic gouty arthropathy 1, 2
• Radiographic changes of gout 1, 2
• Chronic kidney disease 5
• Urolithiasis 5

First-Line ULT: Xanthine Oxidase Inhibitors

• Allopurinol is the first-line agent: start at 100 mg daily and gradually increase until target serum urate is achieved 1
• Febuxostat is an alternative but is associated with increased all-cause and cardiovascular mortality, so not routinely recommended 5

Target Serum Urate Levels

• Below 6 mg/dL for all patients with gout 1, 2
• Below 5 mg/dL for patients with tophi 1

Mandatory Anti-Inflammatory Prophylaxis During ULT Initiation

• Initiate prophylaxis with or just before starting ULT to prevent acute flares 1, 2
• Options include:
  • Low-dose colchicine (0.6 mg once or twice daily) 2
  • Low-dose NSAIDs with gastroprotection if indicated 2
  • Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 2
• Duration: Continue for at least 6 months, or 3 months after achieving target serum urate for patients without tophi 1, 2
• For patients with tophi, continue for 6 months after achieving target serum urate 2
• Failure to provide prophylaxis leads to acute flares and poor medication adherence 1, 2

Lifestyle Modifications

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

Critical Pitfalls to Avoid

• Do not delay treatment beyond 24 hours—effectiveness significantly decreases 2
• Never discontinue ULT during acute attacks—this worsens outcomes 1, 2
• Always provide prophylaxis when initiating ULT—failure to do so causes flares and poor adherence 1, 2
• Do not treat asymptomatic hyperuricemia—pharmacological treatment is not recommended to prevent gouty arthritis, renal disease, or cardiovascular events 1
• Avoid high-dose colchicine regimens—they cause significant gastrointestinal side effects without added benefit 1