What is the recommended management for gout?

Management of Gout

For acute gout flares, initiate treatment within 24 hours using colchicine (1 mg loading dose, then 0.5 mg one hour later), NSAIDs with gastroprotection, or oral corticosteroids (30-35 mg prednisolone equivalent for 3-5 days); for chronic management, start allopurinol at 100 mg daily and titrate every 2-4 weeks to achieve serum uric acid <6 mg/dL, with mandatory colchicine prophylaxis (0.5-1 mg daily) for the first 6 months of urate-lowering therapy. 1, 2

Acute Gout Flare Management

First-Line Treatment Options

• Colchicine: Administer 1 mg loading dose followed by 0.5 mg one hour later on day 1, then 0.5 mg daily thereafter 1, 3

  • Must be started within 12 hours of symptom onset for optimal efficacy 1
  • Avoid in severe renal impairment (CrCl <30 mL/min) and with strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin) 1, 3

• NSAIDs: Use full FDA-approved doses (naproxen, indomethacin, or sulindac) with proton pump inhibitors if gastrointestinal risk factors present 1

  • Contraindicated in severe renal impairment 1
  • COX-2 inhibitors are alternatives for patients with GI contraindications 1

• Corticosteroids: Oral prednisolone 30-35 mg daily (or equivalent) for 3-5 days, or intra-articular injection for monoarticular disease 1

  • Intramuscular triamcinolone acetonide 60 mg is an alternative 1

Second-Line Treatment

• IL-1 blockers: Reserved for patients with frequent flares who have contraindications to all first-line agents 1, 2
  • Current infection is an absolute contraindication 1

Critical Timing

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 1, 2
• Patients should be educated to self-medicate at first warning symptoms 2, 4

Chronic Gout Management: Urate-Lowering Therapy (ULT)

Indications for ULT

ULT should be considered from first presentation and is definitively indicated for: 1, 2, 4

• Recurrent acute attacks (≥2 per year)
• Tophi or chronic arthropathy
• Renal stones
• Young age at presentation (<40 years)
• Very high serum uric acid (>8.0 mg/dL; 480 μmol/L)
• Comorbidities: renal impairment, hypertension, ischemic heart disease, heart failure

Target Serum Uric Acid Levels

• Standard target: <6 mg/dL (360 μmol/L) for all patients, maintained lifelong 1, 2, 4
• Lower target: <5 mg/dL (300 μmol/L) for severe gout with tophi, chronic arthropathy, or frequent attacks until complete crystal dissolution 1, 2, 4
• Avoid: SUA <3 mg/dL long-term 1

First-Line ULT: Allopurinol

Dosing strategy for normal renal function: 1, 5

• Start at 100 mg daily
• Increase by 100 mg increments every 2-4 weeks until SUA target achieved
• Maximum dose: 800 mg daily (doses >300 mg should be divided)
• Average effective dose: 200-300 mg daily for mild gout, 400-600 mg daily for severe tophaceous gout 5

Renal dose adjustments: 1, 5

• CrCl 10-20 mL/min: Maximum 200 mg daily
• CrCl <10 mL/min: Maximum 100 mg daily
• CrCl <3 mL/min: Extend dosing interval beyond daily

Alternative ULT Options

If allopurinol fails to achieve target or is not tolerated: 1, 2

• Switch to febuxostat
• Switch to uricosuric agent (benzbromarone, probenecid)
• Combine xanthine oxidase inhibitor with uricosuric

For refractory severe tophaceous gout: 1, 2

• Pegloticase is indicated when all other drugs at maximal doses (including combinations) have failed

Mandatory Flare Prophylaxis During ULT Initiation

Prophylaxis must be provided for the first 6 months of ULT: 1, 2, 4

• First choice: Colchicine 0.5-1 mg daily 1, 2
  • Reduce dose in renal impairment 1
  • Monitor for neurotoxicity/muscular toxicity, especially with concurrent statin use 1
• Alternative: Low-dose NSAIDs with gastroprotection if colchicine contraindicated or not tolerated 1, 2

Lifestyle Modifications and Non-Pharmacological Management

Dietary Recommendations

• Weight loss: Reduces SUA levels (demonstrated reduction from 570 to 470 μmol/L after 16 weeks) 4
• Avoid: Alcohol (especially beer and spirits), sugar-sweetened beverages, foods high in fructose, purine-rich foods (organ meats, shellfish) 2, 4, 6
• Encourage: Low-fat dairy products, regular exercise 2, 4
• Maintain: Fluid intake sufficient for ≥2 liters daily urinary output 5

Patient Education

• Comprehensive education about disease pathophysiology and lifelong treatment necessity increases adherence to 92% at 12 months 2, 4
• This is the single most important intervention for long-term success 2

Management of Comorbidities

Diuretic-Associated Gout

• Substitute diuretic if possible 1, 2
• For hypertension: Consider losartan or calcium channel blockers 1, 2, 4
• For hyperlipidemia: Consider statin or fenofibrate 1, 4

Mandatory Comorbidity Screening

Screen for and address: renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidemia, and smoking 2, 4

Critical Pitfalls to Avoid

• Never interrupt ongoing ULT during an acute flare 1
• Never treat acute flares with colchicine in patients already on prophylactic colchicine and receiving CYP3A4 inhibitors 3
• Never use colchicine or NSAIDs in severe renal impairment 1
• Never start ULT without concurrent flare prophylaxis 1, 2
• Never treat asymptomatic hyperuricemia with ULT 2

Special Populations

Severe Renal Impairment (CrCl <30 mL/min)

• Colchicine prophylaxis: Start 0.3 mg daily 1
• Acute flare treatment: Single 0.6 mg colchicine dose, repeat no more than once every 2 weeks 3
• Allopurinol: Adjust maximum dose to creatinine clearance 1, 5
• Consider febuxostat or benzbromarone if SUA target not achieved 1

Dialysis Patients

• Colchicine prophylaxis: 0.3 mg twice weekly 1
• Acute flare: Single 0.6 mg dose, no more than once every 2 weeks 3
• ULT: Start allopurinol 0.3 mg daily with careful monitoring 1