From the Guidelines
Conservative management for gout should prioritize lifestyle modifications and medication to control symptoms and prevent future attacks, with a focus on urate-lowering therapy (ULT) and anti-inflammatory prophylaxis, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The management of gout involves a combination of lifestyle modifications, pharmacologic treatments, and patient education. Key lifestyle modifications include:
- Maintaining a healthy weight
- Limiting alcohol consumption, especially beer and spirits
- Avoiding high-purine foods, such as organ meats, shellfish, and red meat
- Staying well-hydrated
- Encouraging low-fat dairy products and regular exercise
During an acute gout attack, first-line treatments include:
- NSAIDs, such as naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 7-10 days
- Colchicine, effective when started early (1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve)
- Oral corticosteroids, such as prednisone (30-40mg daily, tapered over 7-10 days), for those who cannot take NSAIDs or colchicine
For long-term management in patients with recurrent attacks, urate-lowering therapy with allopurinol (starting at 100mg daily, gradually increasing to achieve serum uric acid below 6mg/dL) or febuxostat (40-80mg daily) is recommended 1. These medications work by reducing uric acid production, addressing the underlying cause of gout by preventing the formation and deposition of urate crystals in joints. Some important considerations for ULT include:
- Initiating ULT in all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares
- Using a low starting dose of allopurinol (≤100 mg/day) or febuxostat (≤40 mg/day)
- Titration of ULT dose guided by serial serum urate measurements, with an SU target of <6 mg/dL
- Concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months when initiating ULT 1
From the FDA Drug Label
The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage. The recommended conservative management for gout includes:
- Starting with a low dose of allopurinol (100 mg daily) and increasing at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained
- Maintaining a neutral or slightly alkaline urine
- Having a fluid intake sufficient to yield a daily urinary output of at least 2 liters
- Monitoring serum uric acid levels and adjusting the dosage of allopurinol as needed to maintain a normal serum uric acid level 2
- Considering the use of colchicine or anti-inflammatory agents to suppress gouty attacks in some cases 2
- Adjusting the dosage of allopurinol based on the patient's renal function 2
From the Research
Conservative Management for Gout
- The recommended conservative management for gout includes non-pharmacological and pharmacological interventions 3, 4, 5, 6, 7.
- Non-pharmacological interventions include lifestyle modifications such as diet, weight loss, and avoidance of alcohol and fructose-rich foods 4, 7.
- Pharmacological interventions for acute gout attacks include:
- For long-term urate-lowering therapy, allopurinol and febuxostat are commonly used 4, 6, 7.
- Novel therapies such as verinurad, arhalofenate, and pegloticase are also being developed for the treatment of gout 7.
Treatment of Acute Gout Attacks
- NSAIDs, colchicine, and glucocorticoids are effective for relieving pain in acute gout attacks 3, 5.
- Low-dose colchicine has a comparable tolerability profile to placebo and a significantly lower side effect profile compared to high-dose colchicine 5.
- IL-1β inhibitory antibodies such as canakinumab are effective for arresting flares but are considered salvage therapies due to their high cost 5, 7.
Urate-Lowering Therapy
- Allopurinol is an agent of first choice for urate-lowering therapy, but screening for HLA*B58:01 mutation is recommended in certain populations to decrease the risk of allopurinol hypersensitivity syndrome 7.
- Febuxostat is another efficacious urate-lowering therapy, but has received a US FDA black box warning for cardiovascular safety 7.
- Novel uricosurics such as verinurad and arhalofenate are being developed for the treatment of gout 7.