Gout Treatment
Acute Gout Attack Management
For acute gout attacks, initiate treatment within 24 hours with NSAIDs, low-dose colchicine, or corticosteroids as first-line monotherapy, selecting based on patient comorbidities. 1, 2, 3
Treatment Selection Algorithm
For mild-moderate attacks (1-3 small joints or 1-2 large joints):
NSAIDs at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) are first-line when started promptly and should be continued until complete resolution 1, 2
Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is equally effective as high-dose regimens with significantly fewer gastrointestinal side effects 1, 2, 3
Oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days or 30-35 mg/day for 3-5 days) are particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2, 3
- Avoid in patients with diabetes, active infection, or high infection risk 1
Intra-articular corticosteroid injection is highly effective for single joint involvement or 1-2 accessible affected joints 1, 2, 3
For severe/polyarticular attacks (≥4 joints):
- Combination therapy should be considered, using two or more of the above agents simultaneously 1, 2, 3
Critical Pitfalls to Avoid
- Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
- Never discontinue ongoing urate-lowering therapy during an acute attack—this worsens outcomes 2, 3
- Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours, then switch or add therapy 2
Long-Term Urate-Lowering Therapy (ULT)
Initiate ULT in patients with recurrent attacks (≥2 per year), tophi, chronic gouty arthropathy, radiographic changes of gout, or history of nephrolithiasis, with a target serum urate level of <6 mg/dL (357 μmol/L). 1, 2, 3
First-Line ULT Options
Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line agents 1, 2, 3
Uricosuric agents (probenecid) are alternative options when xanthine oxidase inhibitors cannot be used 3
Mandatory Anti-Inflammatory Prophylaxis During ULT Initiation
Anti-inflammatory prophylaxis must be initiated with or just before starting ULT to prevent flares, as failure to provide prophylaxis leads to acute flares and poor medication adherence. 1, 2, 3
Prophylaxis Regimen
Low-dose colchicine (0.5-0.6 mg once or twice daily) is first-line prophylaxis 1, 2, 3
- Adjust for renal impairment: For severe renal failure (CrCl <30 mL/min), start with 0.3 mg/day; for dialysis patients, start with 0.3 mg per day 4
Low-dose NSAIDs (with proton pump inhibitor if indicated) are an alternative 1, 2, 3
Low-dose prednisone (≤10 mg/day) for patients with contraindications to both colchicine and NSAIDs 1, 2, 3
Duration of Prophylaxis
- Continue for the greater of:
Non-Pharmacologic Measures
- Topical ice application as adjunctive measure during acute attacks 2, 3
- Weight loss for obese patients 1, 2, 3
- Avoid alcoholic drinks (especially beer and spirits) and beverages sweetened with high-fructose corn syrup 1, 2, 3
- Encourage consumption of vegetables and low-fat or nonfat dairy products 5
Key Clinical Pearls
- Patient education should include instructions for self-initiation of treatment upon first signs of an acute attack 3
- High-dose colchicine regimens cause significant gastrointestinal side effects while low-dose regimens are equally effective 2, 3
- Treatment of gout flares with colchicine is not recommended in patients with renal or hepatic impairment who are already receiving colchicine for prophylaxis 4