What are the guidelines for managing gout, including acute attacks and chronic prevention?

Gout Management Guidelines

Acute Gout Attack Treatment

For acute gout flares, initiate treatment within 24 hours with corticosteroids as first-line therapy (oral prednisone 30-35 mg/day for 3-5 days or 0.5 mg/kg/day for 5-10 days), NSAIDs at full anti-inflammatory doses, or low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), with corticosteroids preferred due to their superior safety profile and low cost. 1, 2

Treatment Selection by Attack Severity

Mild attacks (1-2 small joints or 1-2 large joints):

• Monotherapy with any first-line agent is appropriate 3, 2
• NSAIDs: Use full FDA-approved doses (naproxen, indomethacin, or sulindac) 3, 2
• Colchicine: Most effective when started within 12-36 hours of symptom onset 1, 4
• Corticosteroids: Oral prednisone 0.5 mg/kg/day for 5-10 days, then stop or taper over 7-10 days 3, 1
• Intra-articular corticosteroid injection for single joint involvement 1, 2

Severe attacks (polyarticular ≥4 joints or multiple large joints):

• Combination therapy is recommended 3, 2
• Acceptable combinations include: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality 3
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 3

Critical Management Principles

• Continue ongoing urate-lowering therapy without interruption during acute attacks 3, 2, 4
• Treatment delayed beyond 24 hours significantly reduces effectiveness 1, 2, 4
• Inadequate response is defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours 2

Long-Term Urate-Lowering Therapy (ULT)

Do not initiate ULT after a first gout attack or in patients with infrequent attacks (<2 per year); ULT is indicated for recurrent gout flares, tophi, urate arthropathy, or renal stones. 1

Initiating ULT

• Start with low-dose allopurinol 100 mg daily 1, 5
• Increase by 100 mg every 2-4 weeks (weekly intervals per FDA label) 1, 5
• Target serum urate level: <6 mg/dL 1, 2, 5
• Average maintenance dose: 200-300 mg/day for mild gout, 400-600 mg/day for moderately severe tophaceous gout 5
• Maximum dose: 800 mg/day 5

Renal Dosing Adjustments

Patients with renal impairment require dose reduction: 5

• Creatinine clearance 10-20 mL/min: 200 mg daily
• Creatinine clearance <10 mL/min: maximum 100 mg daily
• Creatinine clearance <3 mL/min: 100 mg per day or 300 mg twice weekly, with extended intervals between doses

Prophylaxis During ULT Initiation

Mandatory anti-inflammatory prophylaxis must be initiated with or just prior to starting ULT to prevent acute flares. 3, 1, 2, 5

First-Line Prophylaxis Options

• Low-dose colchicine: 0.6 mg once or twice daily (0.5 mg outside US) 3, 1, 2
• Low-dose NSAIDs with proton pump inhibitor where indicated (e.g., naproxen 250 mg twice daily) 3, 1, 2

Second-Line Prophylaxis

• Low-dose prednisone/prednisolone (<10 mg/day) if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 3, 1, 2

Duration of Prophylaxis

Continue prophylaxis for: 3, 1, 2

• At least 6 months minimum
• OR 3 months after achieving target serum urate if no tophi present
• OR 6 months after achieving target serum urate if tophi are present

Non-Pharmacologic Management

• Weight loss for obese patients 1, 2
• Limit alcohol intake, especially beer 1, 2, 6
• Avoid beverages sweetened with high-fructose corn syrup and sugar-sweetened beverages 1, 6
• Limit purine-rich foods (organ meats, shellfish) 6
• Encourage consumption of vegetables and low-fat/nonfat dairy products 6
• Maintain fluid intake sufficient to yield daily urinary output of at least 2 liters 5
• Maintain neutral or slightly alkaline urine 5
• Topical ice application during acute attacks 2

Special Populations

Renal impairment:

• Corticosteroids are safer than NSAIDs or colchicine 1
• Adjust allopurinol dosing based on creatinine clearance 1, 5
• Monitor BUN and renal function closely during early allopurinol therapy 5

Hepatic impairment:

• Consider colchicine dose reduction 1
• Monitor closely for adverse effects 1

Cardiovascular disease:

• Avoid NSAIDs in patients with heart failure, significant renal disease, or cirrhosis 1, 2

Common Pitfalls and Caveats

• Stopping ULT during acute flares worsens and prolongs attacks 2, 4
• Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 2, 5
• High-dose colchicine regimens cause significant gastrointestinal side effects without additional benefit 4, 7
• Starting allopurinol at high doses increases risk of acute flares 5
• NSAIDs should be avoided in patients with peptic ulcer disease, heart failure, or significant renal disease 2
• Monitor for colchicine drug interactions, particularly with CYP3A4 inhibitors and P-glycoprotein inhibitors 4
• Bone marrow depression can occur with allopurinol, especially with concomitant myelosuppressive drugs 5
• Patients on mercaptopurine or azathioprine require dose reduction to one-third to one-fourth when starting allopurinol 5