Gout Treatment
Acute Gout Attack Management
For acute gout attacks, initiate treatment within 24 hours of symptom onset with first-line options including low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs at full anti-inflammatory doses, or corticosteroids, with the choice depending on contraindications and joint involvement. 1, 2, 3
First-Line Treatment Options
- Low-dose colchicine is most effective when started within 12 hours of symptom onset, using 1.2 mg followed by 0.6 mg one hour later—this regimen is equally effective as higher doses but with significantly fewer gastrointestinal side effects 1, 2
- NSAIDs at full anti-inflammatory doses (such as naproxen 500 mg twice daily) should be started promptly, but must be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 3
- Oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days or prednisone 0.5 mg/kg per day for 5-10 days) are particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2, 3
- Intra-articular corticosteroid injection is highly effective for single joint involvement and is the preferred option for NPO patients with 1-2 affected joints 1, 2, 3
Treatment Algorithm Based on Severity
- For mild attacks (1-3 small joints or 1-2 large joints): Use monotherapy with any of the above first-line options 3
- For severe pain (≥7/10) or polyarticular involvement: Consider combination therapy such as colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 1
- For NPO patients with multiple joint involvement: Use intravenous/intramuscular methylprednisolone (0.5-2.0 mg/kg) or subcutaneous ACTH (25-40 IU) 1
Special Population Considerations
- Renal impairment: Corticosteroids are safer than NSAIDs or colchicine; for severe renal failure or dialysis patients, colchicine dose should be reduced to a single 0.6 mg dose, with treatment courses repeated no more than once every two weeks 1, 4
- Hepatic impairment: For severe hepatic dysfunction, treatment courses should be repeated no more than once every two weeks 4
Critical Management Principles
- Continue established urate-lowering therapy without interruption during acute attacks—discontinuing therapy worsens outcomes 1, 3
- Educate patients to self-medicate at first warning symptoms using a "pill in the pocket" approach 1
- Apply topical ice as an adjunctive measure during acute attacks 1, 3
- Consider inadequate response if there is <20% improvement in pain within 24 hours or <50% improvement after 24 hours, then switch to another monotherapy or add a second agent 1
Important Drug Interaction Warning
- Colchicine has serious drug interactions with strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin—these must be carefully considered to avoid potentially fatal toxicity 1, 4
Long-Term Urate-Lowering Therapy
Do not initiate urate-lowering therapy after a first gout attack or in patients with infrequent attacks; reserve it for patients with recurrent acute attacks, tophi, chronic gouty arthropathy, or radiographic changes of gout. 1, 3
Indications for Urate-Lowering Therapy
- Recurrent acute attacks 1, 3
- Tophi 1, 3
- Chronic gouty arthropathy 1, 3
- Radiographic changes of gout 1, 3
First-Line Urate-Lowering Agents
- Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options for urate-lowering therapy 1, 2, 3
- Allopurinol should be started at no greater than 100 mg/day and gradually titrated upward every 2-5 weeks to reach target serum urate 3
- Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations including Koreans with CKD, Han Chinese, or Thai patients 3
Alternative Urate-Lowering Agents
- Uricosuric agents (probenecid or benzbromarone) are alternatives in patients with normal renal function and no history of urolithiasis 1, 2, 3
Target Serum Urate Level
Prophylaxis During Urate-Lowering Therapy Initiation
Anti-inflammatory prophylaxis is mandatory when starting urate-lowering therapy to prevent flares, using low-dose colchicine (0.5-0.6 mg once or twice daily), low-dose NSAIDs with gastroprotection, or low-dose prednisone. 1, 2, 3
Prophylaxis Duration
- Continue prophylaxis for at least 6 months 1, 2, 3
- OR for 3 months after achieving target serum urate if no tophi are present 1, 3
- OR for 6 months after achieving target serum urate if tophi have resolved 1, 3
Critical Importance
- Inadequate duration of prophylaxis leads to breakthrough flares and poor medication adherence—this is one of the most common causes of treatment failure 1, 3
Non-Pharmacologic Measures
- Weight loss is recommended for obese patients 1, 2, 3
- Avoid alcoholic drinks, especially beer, and beverages sweetened with high-fructose corn syrup 1, 3
- Encourage consumption of vegetables and low-fat or nonfat dairy products 5
- Consider discontinuing loop and thiazide diuretics if possible, as they increase uric acid levels 5
- Consider losartan for hypertensive patients, as it increases urinary excretion of uric acid 5
Common Pitfalls and How to Avoid Them
- Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness—educate patients to start treatment immediately 1, 3
- Using high-dose colchicine regimens causes significant gastrointestinal side effects with no additional benefit—always use the low-dose regimen 1, 3
- Discontinuing urate-lowering therapy during acute flares worsens outcomes—continue established therapy without interruption 1, 3
- Failing to provide prophylaxis when initiating urate-lowering therapy leads to acute flares and poor adherence—always provide prophylaxis for the appropriate duration 1, 3
- Prescribing NSAIDs to patients with contraindications—carefully screen for heart failure, peptic ulcer disease, and significant renal disease 1, 3
- Ignoring colchicine drug interactions—always check for P-glycoprotein and CYP3A4 inhibitors 1, 4