What are the management options for gout?

Management of Gout

Gout management requires a dual approach: aggressive early treatment of acute flares with colchicine, NSAIDs, or corticosteroids, combined with lifelong urate-lowering therapy targeting serum uric acid <6 mg/dL for patients with recurrent attacks, tophi, or chronic kidney disease. 1, 2

Acute Gout Flare Management

Treat acute flares as early as possible—ideally within 12-24 hours of symptom onset—as timing is the most critical determinant of therapeutic success. 2, 3

First-Line Treatment Options (Choose One or Combine):

• Colchicine: Loading dose of 1 mg followed by 0.5 mg one hour later (total 1.5 mg on day 1), then 0.5 mg daily. Most effective when started within 12 hours of symptom onset. 2, 1

• NSAIDs: Use full anti-inflammatory doses with proton pump inhibitor gastroprotection when appropriate. The specific NSAID chosen matters less than early initiation. 2, 3

• Corticosteroids: Oral prednisolone 30-35 mg/day for 3-5 days, or intra-articular injection for monoarticular disease. Particularly useful when NSAIDs or colchicine are contraindicated. 2, 1

Non-Pharmacologic Measures:

• Topical ice application and rest of the inflamed joint provide adjunctive benefit. 3

Indications for Urate-Lowering Therapy (ULT)

Initiate lifelong ULT for any patient with: 1, 2

• Tophus or tophi (by clinical exam or imaging)
• Frequent attacks (≥2 per year)
• Chronic kidney disease stage 2 or worse
• Past urolithiasis
• Radiographic damage attributable to gout
• Chronic gouty arthritis

Consider ULT from first presentation of disease according to EULAR guidelines. 1

Urate-Lowering Therapy: Treat-to-Target Approach

The target serum uric acid is <6 mg/dL (360 μmol/L), maintained lifelong. For severe gout with tophi, target <5 mg/dL (300 μmol/L) to improve disease signs and symptoms. 1, 2

First-Line ULT:

Allopurinol is the preferred first-line agent, including for patients with moderate-to-severe chronic kidney disease (stage ≥3). 1, 2, 4

• Starting dose: 100 mg daily 4, 2
• Titration: Increase by 100 mg every 2-4 weeks (or weekly per FDA label) until target serum urate is achieved 4, 1
• Typical maintenance dose: 200-300 mg/day for mild gout; 400-600 mg/day for moderately severe tophaceous gout 4
• Maximum dose: 800 mg/day in divided doses 4
• Renal dosing adjustments: 4
  • CrCl 10-20 mL/min: 200 mg daily maximum
  • CrCl <10 mL/min: 100 mg daily maximum
  • CrCl <3 mL/min: extend interval between doses

Important caveat: Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with stage 3 or worse CKD; Han Chinese and Thai irrespective of renal function) to prevent severe hypersensitivity reactions. 1

Second-Line and Alternative ULT Options:

If serum urate target cannot be achieved with appropriately dosed allopurinol: 1

• Febuxostat: Can be substituted for allopurinol in cases of drug intolerance or after failure of upward dose titration. Should not be used in combination with allopurinol. 1

• Uricosuric agents: 1

  • Probenecid: First choice among uricosurics for monotherapy, but not recommended if CrCl <50 mL/min
  • Contraindications for uricosurics: History of urolithiasis, elevated urinary uric acid indicating overproduction
  • Monitoring: Measure urinary uric acid before initiation and continue monitoring during therapy
  • Risk mitigation: Consider urine alkalinization (e.g., potassium citrate) with urine pH monitoring, plus increased fluid intake (≥2 liters daily urinary output) to prevent urolithiasis

• Combination therapy: Add a uricosuric agent (probenecid, fenofibrate, or losartan) to a xanthine oxidase inhibitor, or vice versa. 1

Refractory Gout:

Pegloticase is appropriate for patients with severe gout disease burden and refractoriness to, or intolerance of, conventional and appropriately dosed ULT. It is not recommended as first-line therapy. 1

• Discontinue all oral ULT agents during pegloticase therapy to avoid masking loss of efficacy and increased risk of infusion reactions. 1

Flare Prophylaxis During ULT Initiation

Mandatory prophylaxis for at least 3-6 months when initiating or adjusting ULT to prevent mobilization flares. 2, 5

Prophylaxis Options:

• Colchicine 0.5-1 mg daily: First choice for prophylaxis 2, 5

  • Reduce to 0.5 mg daily or every other day if CrCl 30-50 mL/min 2

• Low-dose NSAIDs: Alternative if colchicine is contraindicated or not tolerated 5

• Low-dose corticosteroids: Alternative option 2

Continue prophylaxis until: 1

• Serum urate has been normalized
• Patient has been free from acute gouty attacks for several months
• All palpable tophi and chronic gouty arthritis symptoms have resolved

Lifestyle and Dietary Modifications

Comprehensive lifestyle counseling reduces both hyperuricemia and mortality. 2, 5

Dietary Recommendations:

Limit or avoid: 2, 5

• Alcohol (especially beer and spirits)
• Sugar-sweetened drinks and high-fructose corn syrup
• Excessive red meat and organ meats
• Shellfish and seafood

Encourage: 2, 5

• Low-fat or nonfat dairy products
• Vegetables
• Regular exercise
• Weight loss if obese
• Cherry or cherry juice extract (may reduce attack frequency) 6
• Vitamin C supplementation (may lower serum uric acid) 6

Medication Adjustments:

Substitute diuretics if possible, as they promote hyperuricemia. 1, 5

Consider switching to medications with uricosuric properties: 1, 2

• Losartan (modest uricosuric effects) for hypertension
• Calcium channel blockers for hypertension
• Fenofibrate (has uricosuric properties) for hyperlipidemia

Patient Education

Patient education is the single most important intervention, increasing adherence to ULT to 92% at 12 months. 5

Core knowledge points to convey: 5, 6

• Gout is a chronic disease requiring lifelong management
• Hyperuricemia causes crystal deposition leading to attacks and joint damage
• ULT prevents future attacks and dissolves existing crystals
• Patients should self-medicate acute flares at first warning symptoms
• Do not discontinue ULT during acute flares

Common Pitfalls to Avoid

Critical errors that compromise outcomes: 2

• Delaying treatment beyond 24 hours of acute flare symptom onset
• Discontinuing ULT during acute flares (continue ULT and add anti-inflammatory therapy)
• Inadequate prophylaxis duration when initiating ULT (must continue ≥3-6 months)
• Using high-dose colchicine regimens (outdated; use low-dose protocol)
• Insufficient allopurinol dosing (must titrate to achieve target serum urate, not stop at arbitrary dose)
• Failing to monitor serum urate levels to confirm target achievement
• Treating asymptomatic hyperuricemia (not indicated per FDA label and guidelines) 4, 5

Comorbidity Screening and Management

Systematic screening for cardiovascular comorbidities is mandatory for all gout patients, as these interventions reduce both hyperuricemia and mortality. 2, 5

Screen for: 5

• Renal impairment
• Coronary heart disease
• Hypertension
• Obesity
• Metabolic syndrome
• Type 2 diabetes

Long-Term Management Strategy

After achieving target serum urate and resolution of all symptoms: 1

• Continue all measures (including pharmacologic ULT) needed to maintain serum urate <6 mg/dL indefinitely
• Regularly monitor serum urate levels
• Monitor for ULT side effects
• Maintain lifestyle modifications

Referral to specialist should be considered for: 1

• Unclear etiology of hyperuricemia
• Refractory signs or symptoms of gout
• Difficulty reaching target serum urate, particularly with renal impairment
• Multiple or serious adverse events from pharmacologic ULT