What are the treatment options for managing gout?

Management of Gout

For acute gout attacks, initiate corticosteroids, NSAIDs, or low-dose colchicine within 24 hours of symptom onset, with corticosteroids preferred as first-line therapy due to superior safety profile and equivalent efficacy. 1

Acute Gout Attack Management

First-Line Treatment Options

Corticosteroids should be your first choice in patients without contraindications (systemic fungal infections) because they are safer than NSAIDs and equally effective, with fewer adverse effects. 1

• Oral corticosteroids: Prednisolone 30-35 mg/day for 3-5 days 1
• Intra-articular injection: Highly effective for single joint involvement 1
• Adverse effects with short-term use include dysphoria, mood disorders, elevated blood glucose, immune suppression, and fluid retention 1

NSAIDs at full anti-inflammatory doses are effective when started promptly, but carry significant risks. 1

• All NSAIDs are equally effective—indomethacin has no advantage over naproxen or ibuprofen 1
• Contraindications: Renal disease, heart failure, cirrhosis, peptic ulcer disease 1
• Adverse effects include dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding 1

Low-dose colchicine is effective but more expensive than corticosteroids or NSAIDs. 1

• Dosing: 1.2 mg loading dose followed by 0.6 mg one hour later (total 1.8 mg over one hour) 1, 2
• Most effective when started within 12 hours of symptom onset 1
• High-dose regimens provide no additional benefit and cause significantly more gastrointestinal side effects 1
• Contraindications: Severe renal or hepatic impairment, concurrent use of strong CYP3A4 inhibitors (cyclosporin, clarithromycin) or P-glycoprotein inhibitors 1, 2

Critical Timing Principle

Treatment must begin within 24 hours of symptom onset for optimal outcomes—delaying beyond this window substantially reduces effectiveness. 3, 4

Combination Therapy for Severe Presentations

For severe pain (≥7/10) or polyarticular involvement, use combination therapy: 3

• Colchicine plus NSAIDs
• Oral corticosteroids plus colchicine
• Intra-articular steroids with any other modality

Continue Established Urate-Lowering Therapy

Do not discontinue urate-lowering therapy during acute attacks—this common error worsens outcomes. 3, 4

Long-Term Management with Urate-Lowering Therapy (ULT)

Indications for ULT

Do not initiate ULT after a first gout attack or in patients with infrequent attacks. 1

Initiate ULT for: 3, 4

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

First-Line ULT: Xanthine Oxidase Inhibitors

Allopurinol is the preferred first-line agent. 3, 4

• Starting dose: 100 mg daily (never higher) 4
• Titration: Increase by 100 mg every 2-5 weeks until target achieved 4
• Target serum urate: <6 mg/dL (360 μmol/L) lifelong 3, 5
• Consider HLA-B*5801 testing before initiating in high-risk populations (Koreans with CKD, Han Chinese, Thai) 4

Febuxostat is an alternative xanthine oxidase inhibitor but is associated with increased all-cause and cardiovascular mortality, so is not routinely recommended. 6

Alternative ULT: Uricosuric Agents

Probenecid or benzbromarone are alternatives when xanthine oxidase inhibitors cannot be used. 3, 4

• Reserved for patients with normal renal function and no history of urolithiasis 1
• Fenofibrate has uricosuric properties and may be useful in patients with concurrent hyperlipidemia 5

Mandatory Flare Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis is absolutely required when starting ULT to prevent mobilization flares. 1, 3, 4

Prophylaxis Options

• Low-dose colchicine: 0.5-1 mg daily (first-line) 1, 3
  • Reduce to 0.5 mg daily or every other day if creatinine clearance 30-50 mL/min 5
• Low-dose NSAIDs with gastroprotection if indicated 3, 4
• Low-dose prednisone 3

Duration of Prophylaxis

Continue prophylaxis for at least 6 months when starting ULT, or: 1, 3

• 3 months after achieving target serum urate if no tophi present
• 6 months after achieving target serum urate if tophi were present

Inadequate prophylaxis duration leads to breakthrough flares and poor medication adherence—this is a common pitfall. 3, 4

Non-Pharmacologic Measures

Every patient with gout must receive comprehensive lifestyle counseling: 1, 5

• Weight loss if obese 1, 5
• Avoid alcohol, especially beer and spirits 1, 5
• Eliminate sugar-sweetened drinks and foods high in fructose 1, 5
• Reduce intake of red meat and seafood 1, 5
• Encourage low-fat dairy products 1, 5
• Regular exercise 5
• Topical ice application during acute attacks 3, 4

Management of Comorbidities

Systematically screen for and address associated comorbidities: 1

• Renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease
• Obesity, hyperlipidemia, hypertension, diabetes, smoking

Medication Adjustments

If taking thiazide or loop diuretics, substitute if possible as these are the most common iatrogenic cause of gout. 5

• Switch to losartan (modest uricosuric effects) or calcium channel blockers for hypertension 5
• Consider fenofibrate for hyperlipidemia (has uricosuric properties) 5

Special Populations

Renal Impairment

Corticosteroids are safer than NSAIDs or colchicine in patients with renal disease. 1

• Colchicine and NSAIDs should be avoided in severe renal impairment 1
• Dose-reduce colchicine prophylaxis if creatinine clearance 30-50 mL/min 5

NPO Patients

• For 1-2 affected joints: Intra-articular corticosteroid injection 3
• For multiple joint involvement: IV/IM methylprednisolone (0.5-2.0 mg/kg) or subcutaneous ACTH (25-40 IU) 3

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours substantially reduces effectiveness 3, 4
• Using high-dose colchicine regimens causes significant GI side effects with no additional benefit 1, 3
• Discontinuing ULT during acute flares worsens outcomes 3, 4
• Failing to provide prophylaxis when initiating ULT leads to breakthrough flares and poor adherence 3, 4
• Ignoring drug interactions with colchicine, particularly with strong CYP3A4 or P-glycoprotein inhibitors, can cause serious toxicity 1, 2
• Monitoring serum urate levels has insufficient evidence to support routine practice 1