What is the recommended management for gouty arthritis?

Management of Gouty Arthritis

Acute Gout Attack Treatment

For acute gouty arthritis, initiate treatment within 24 hours of symptom onset with NSAIDs, oral colchicine, or corticosteroids as first-line monotherapy options, with the choice determined by pain severity, number of joints involved, and patient contraindications. 1, 2, 3

First-Line Monotherapy Options

NSAIDs:

• Use full FDA-approved anti-inflammatory doses (naproxen 500mg twice daily, indomethacin, or sulindac) and continue until the attack completely resolves 2, 4
• Most effective when started early; the timing of initiation matters more than which specific NSAID is chosen 5
• Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease 2, 3

Colchicine:

• Low-dose regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2, 3
• This low-dose approach is as effective as higher doses with significantly fewer gastrointestinal side effects 2, 3
• Most effective when started within 36 hours of symptom onset 3
• Requires dose adjustment in moderate to severe chronic kidney disease and with drug interactions involving CYP3A4 and P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine) 6

Corticosteroids:

• For 1-2 joints: Oral prednisone 0.5 mg/kg per day for 5-10 days followed by discontinuation, OR 2-5 days at full dose followed by tapering for 7-10 days 6, 2
• Alternative: Intramuscular triamcinolone acetonide 60 mg single dose followed by oral prednisone 6
• For 1-2 large joints: Intra-articular corticosteroid injection is highly effective and can be combined with oral agents 6, 2
• Particularly useful when NSAIDs and colchicine are contraindicated 2
• Use with caution in diabetic patients due to hyperglycemia risk 3

Combination Therapy Indications

For severe attacks (pain ≥7/10 on visual analog scale) or polyarticular involvement (≥4 joints), use combination therapy with full doses of two agents simultaneously: 6, 2

• Colchicine + NSAIDs
• Oral corticosteroids + colchicine
• Intra-articular steroids + any oral agent 6

Critical pitfall: Do NOT combine NSAIDs with systemic corticosteroids due to increased gastrointestinal toxicity risk 1

Treatment Response Monitoring

Inadequate response is defined as: 2

• <20% improvement in pain within 24 hours, OR
• <50% improvement after 24 hours of therapy

If inadequate response occurs, add a second agent 3

Management During Urate-Lowering Therapy

Continue established urate-lowering therapy (ULT) without interruption during an acute attack—stopping ULT can worsen and prolong the attack. 1, 2

Anti-Inflammatory Prophylaxis (Mandatory)

When initiating ULT, anti-inflammatory prophylaxis is essential to prevent acute flares: 1, 2, 7

First-line prophylactic options: 2, 3

• Low-dose colchicine (0.6 mg once or twice daily)
• Low-dose NSAIDs with proton pump inhibitor when indicated
• Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated

Duration of prophylaxis: 2, 3

• At least 6 months after starting ULT 1
• OR 3 months after achieving target serum urate (<6 mg/dL) if no tophi present
• OR 6 months after achieving target serum urate if tophi are present

Urate-Lowering Therapy Initiation

Start with low-dose allopurinol (100 mg daily) and increase by 100 mg at weekly intervals until serum uric acid reaches <6 mg/dL, without exceeding 800 mg daily: 7

• Target serum urate: <6 mg/dL for all patients 2
• Average maintenance dose: 200-300 mg/day for mild gout, 400-600 mg/day for moderately severe tophaceous gout 7
• In renal impairment: Creatinine clearance 10-20 mL/min = 200 mg daily; <10 mL/min = 100 mg daily maximum 7

The gradual dose escalation combined with prophylaxis prevents the acute flare increase that commonly occurs during the first months of ULT initiation 7, 8

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2
• Stopping ULT during acute attacks worsens outcomes 1, 2
• Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 2, 8
• Starting allopurinol at high doses without prophylaxis triggers acute attacks 7
• Inadequate fluid intake during ULT—maintain daily urinary output of at least 2 liters 7

Adjunctive Non-Pharmacologic Measures

• Topical ice application during acute attacks 2
• Weight loss for obese patients 2
• Avoid alcoholic beverages (especially beer) and high-fructose corn syrup-sweetened drinks 2, 9
• Limit purine-rich foods (organ meats, shellfish) 9
• Increase consumption of vegetables and low-fat dairy products 9