What are the steps for treating gout?

Treatment of Gout: Step-by-Step Approach

Acute Gout Attack Management

Initiate pharmacologic therapy within 24 hours of symptom onset for optimal outcomes, and continue established urate-lowering therapy without interruption during acute attacks. 1, 2, 3

Step 1: Assess Attack Severity and Joint Involvement

• Mild-to-moderate attacks (1-3 small joints or 1-2 large joints): Use monotherapy with NSAIDs, low-dose colchicine, or corticosteroids 1, 2, 3
• Severe or polyarticular attacks (≥4 joints): Consider combination therapy or add intra-articular corticosteroid injection for accessible joints 1, 2, 4

Step 2: Select First-Line Monotherapy Based on Comorbidities

NSAIDs at Full Anti-Inflammatory Doses 1, 2, 3

• Use naproxen, indomethacin, or sulindac at FDA-approved doses for acute gout 1
• Continue at full dose until the attack completely resolves 1
• Avoid in patients with: chronic kidney disease, congestive heart failure, peptic ulcer disease, cirrhosis, or significant renal disease 2, 4, 3

Low-Dose Colchicine 1, 2, 3

• Dosing: 1.2 mg followed by 0.6 mg one hour later 1, 2, 3
• Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 1, 2, 4
• Do not use if patient is already on prophylactic colchicine 1, 5
• Renal adjustments: For severe renal impairment (CrCl <30 mL/min) or dialysis patients, reduce to single 0.6 mg dose and do not repeat more than once every two weeks 5
• Hepatic adjustments: For severe hepatic impairment, do not repeat treatment course more than once every two weeks 5

Oral Corticosteroids 1, 2, 3

• Dosing: Prednisone 0.5 mg/kg per day (or 30-35 mg/day) for 5-10 days at full dose, then stop OR taper over 7-10 days 1, 4
• Particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2
• Avoid in patients with: diabetes, active infection, or high infection risk 2

Intra-articular Corticosteroid Injection 1, 2, 3

• Highly effective for single joint involvement or 1-2 accessible affected joints 1, 2
• Dose varies depending on joint size 1

Step 3: Monitor Treatment Response

• Inadequate response is defined as: <20% improvement in pain within 24 hours OR <50% improvement after 24 hours 1, 2
• If inadequate response, switch to alternative monotherapy or add combination therapy 1

Step 4: Adjunctive Non-Pharmacologic Measures

• Apply topical ice to affected joints 2, 3
• Rest the inflamed joint 6

---

Long-Term Urate-Lowering Therapy (ULT)

Step 5: Determine Indications for ULT

Initiate ULT in patients with: 2, 3

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

Step 6: Initiate Anti-Inflammatory Prophylaxis BEFORE or WITH ULT

Prophylaxis is mandatory when starting ULT to prevent acute flares. 2, 4, 3

First-line prophylactic options: 2, 4, 3

• Low-dose colchicine: 0.5-0.6 mg once or twice daily, adjusted for renal function and drug interactions 2, 4, 3
• Low-dose NSAIDs: Such as naproxen, with proton pump inhibitor if indicated for gastroprotection 2, 4, 3
• Low-dose prednisone: ≤10 mg/day if colchicine and NSAIDs are contraindicated 2, 4

Duration of prophylaxis: 2, 4, 3

• Continue for at least 6 months, OR
• 3 months after achieving target serum urate (<6 mg/dL) in patients without tophi, OR
• 6 months after achieving target serum urate and resolution of tophi in patients with tophi 2, 4, 3

Step 7: Start Xanthine Oxidase Inhibitor as First-Line ULT

Allopurinol 2, 4, 3

• Starting dose: No greater than 100 mg/day (50 mg/day in stage 4 or worse CKD) 4, 3
• Titrate 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

Febuxostat 2, 3

• Alternative xanthine oxidase inhibitor when allopurinol cannot be used 2, 3

Target serum urate level: <6 mg/dL (357 μmol/L) 2, 4, 3

Step 8: Consider Alternative ULT if Xanthine Oxidase Inhibitors Fail

Uricosuric agents (probenecid) 3, 6

• Use when xanthine oxidase inhibitors cannot be used 3
• Preferred in allopurinol-allergic patients with normal renal function and no history of urolithiasis 6

---

Lifestyle and Dietary Modifications

Step 9: Implement Non-Pharmacologic Interventions

Dietary recommendations: 2, 3, 7

• Limit purine-rich foods (organ meats, shellfish) 7
• Avoid alcoholic drinks, especially beer and spirits 2, 4, 3, 7
• Avoid beverages sweetened with high-fructose corn syrup 2, 3, 7
• Encourage consumption of vegetables and low-fat or nonfat dairy products 7

Weight management: 2, 4, 3

• Weight loss is recommended for obese patients 2, 4, 3

---

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
• Never discontinue ULT during acute attacks—this worsens outcomes 1, 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 2, 3
• Do not treat acute gout flares with colchicine in patients already on prophylactic colchicine 1, 5
• NSAIDs share cardiovascular and renal risks with selective COX-2 inhibitors 1