What are the treatment guidelines for gout?

Treatment Guidelines for Gout

Acute Gout Attack Management

For acute gout attacks, initiate treatment within 24 hours using NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days) as first-line monotherapy, selecting based on patient comorbidities and contraindications. 1

Treatment Selection Algorithm

For attacks involving 1-3 small joints or 1-2 large joints:

• NSAIDs (naproxen, indomethacin, or sulindac at full anti-inflammatory doses) are preferred when started promptly and should be continued until complete resolution 1
• Low-dose colchicine is most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 2, 3
• Oral corticosteroids (prednisone 30-35 mg/day for 3-5 days or 0.5 mg/kg per day for 5-10 days) are particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2
• Intra-articular corticosteroid injection is highly effective for single joint involvement 1

For severe pain or polyarticular involvement (≥4 joints):

• Combination therapy should be considered 1, 2

Critical Contraindications to Consider

NSAIDs must be avoided in patients with:

• Chronic kidney disease 3
• Heart failure 1, 2
• Peptic ulcer disease 1
• Cirrhosis 2, 3

Corticosteroids should be avoided in patients with:

• Diabetes 3
• Active infection or high infection risk 3

Colchicine requires dose adjustment:

• For renal impairment: In severe renal impairment (CrCl <30 mL/min), treatment course should be repeated no more than once every two weeks 4
• For dialysis patients: Reduce to single dose of 0.6 mg, not repeated more than once every two weeks 4
• When combined with CYP3A4 inhibitors: Dose must be reduced significantly 4

Adjunctive Measures

• Apply topical ice to the affected joint 1, 3

Common Pitfall

Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 1. Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours 1.

---

Long-Term Urate-Lowering Therapy (ULT)

Initiate ULT in patients with recurrent acute attacks (≥2 per year), tophi, chronic gouty arthropathy, radiographic changes of gout, or history of nephrolithiasis. 1, 3

First-Line ULT Options

Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options for ULT 1, 2

Allopurinol dosing:

• Starting dose: 100 mg/day (50 mg/day in stage 4 or worse CKD) 2
• Titrate gradually until target serum urate is achieved 3

Target Serum Urate Levels

• Below 6 mg/dL for all patients 1, 2
• Below 5 mg/dL for patients with tophi 3

Critical Management Principle

Ongoing ULT should NOT be interrupted during an acute gout attack 1, 3. Discontinuing ULT during acute attacks can worsen outcomes 1, 3.

---

Anti-Inflammatory Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis is mandatory when starting ULT to prevent flares and must be initiated with or just before starting ULT. 1, 2, 3

First-Line Prophylactic Options

Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) is the first-line prophylaxis option 2, 3

Alternative options:

• Low-dose NSAIDs with gastroprotection if indicated 1
• Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 1, 3

Duration of Prophylaxis

For patients without tophi:

• Continue for at least 6 months OR 3 months after achieving target serum urate, whichever is greater 1, 2, 3

For patients with tophi:

• Continue for 6 months after achieving target serum urate AND resolution of tophi 2, 3

Critical Pitfall

Failure to provide prophylaxis when initiating ULT often leads to acute flares and poor medication adherence 1, 3. Treatment of gout flares with colchicine is not recommended in patients already receiving prophylactic colchicine with CYP3A4 inhibitors 4.

---

Non-Pharmacologic Measures

Weight loss is recommended for obese patients 1, 2

Dietary modifications:

• Avoid alcoholic drinks, especially beer and spirits 1, 2, 3
• Avoid beverages sweetened with high-fructose corn syrup 1, 3
• Limit purine-rich foods (organ meats, shellfish) 5
• Encourage consumption of vegetables and low-fat or nonfat dairy products 3, 5

---

Special Populations

Renal Impairment

For prophylaxis in severe renal impairment (CrCl <30 mL/min):

• Starting dose should be 0.3 mg/day with close monitoring 4

For dialysis patients:

• Starting dose should be 0.3 mg given twice weekly with close monitoring 4

Hepatic Impairment

For severe hepatic impairment:

• Dose reduction should be considered for prophylaxis 4
• For acute treatment, repeat courses no more than once every two weeks 4