What are the guidelines for treating gout?

Guidelines for Gout Treatment

Acute Gout Flare Management

For acute gout flares, initiate treatment within 24 hours using colchicine, NSAIDs, or oral/intraarticular/intramuscular glucocorticoids as first-line monotherapy, selecting based on patient comorbidities and contraindications. 1

First-Line Treatment Options (Choose One)

• Low-dose colchicine (1.2 mg immediately followed by 0.6 mg one hour later) is strongly recommended over high-dose regimens due to similar efficacy with fewer gastrointestinal side effects 1, 2

  • Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 3, 4
  • Adjust dose for renal impairment: in severe renal failure (CrCl <30 mL/min), use single 0.6 mg dose and do not repeat more than once every two weeks 2

• NSAIDs at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) should be started promptly and continued until complete resolution 3, 4

  • Avoid in patients with chronic kidney disease, congestive heart failure, peptic ulcer disease, or cirrhosis 3, 5, 4

• Oral corticosteroids (prednisone 0.5 mg/kg per day for 5-10 days or 30-35 mg/day for 3-5 days) are particularly useful when NSAIDs or colchicine are contraindicated 3, 5, 4

• Intra-articular corticosteroid injection is highly effective for single joint involvement (1-2 accessible joints) 3, 4

Severe or Polyarticular Attacks

• For attacks involving ≥4 joints or severe pain, combination therapy should be considered 3, 5

• Parenteral glucocorticoids (intramuscular, intravenous, or intraarticular) are strongly recommended over IL-1 inhibitors or ACTH for patients unable to take oral medications 1

Adjunctive Measures

• Topical ice application is conditionally recommended as an adjuvant treatment during acute attacks 1, 3, 4

Critical Timing Consideration

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 3, 4

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Long-Term Urate-Lowering Therapy (ULT)

Initiate ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares (≥2 flares/year). 1

Indications for ULT

• Recurrent acute attacks 1, 3, 4
• Tophi (subcutaneous or imaging-detected) 1, 3
• Chronic gouty arthropathy 1, 3
• Radiographic changes of gout 1, 3
• History of nephrolithiasis 1

First-Line ULT: Allopurinol

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

• Start with low dose (≤100 mg/day, lower in CKD) and titrate upward every 2-5 weeks by 100 mg increments until target serum urate is achieved 1, 6

  • For CrCl 10-20 mL/min: maximum 200 mg/day 6
  • For CrCl <10 mL/min: maximum 100 mg/day 6
  • Maximum recommended dose: 800 mg/day 6

• Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with CKD, Han Chinese, Thai) 4

Alternative ULT Options

• Febuxostat (start <40 mg/day) is an alternative xanthine oxidase inhibitor 1

• Uricosuric agents (probenecid) are alternatives when xanthine oxidase inhibitors cannot be used, effective when CrCl >50 mL/min 4, 7

Target Serum Urate Level

• Treat-to-target strategy with serum urate <6 mg/dL is strongly recommended 1, 3, 5, 4

Switching ULT Strategy

• For patients on maximum-tolerated XOI monotherapy not at target with frequent flares or nonresolving tophi, conditionally recommend switching to an alternate XOI over adding a uricosuric 1

• For patients where XOI, uricosurics, and other interventions have failed with frequent flares or nonresolving tophi, strongly recommend switching to pegloticase 1

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Anti-Inflammatory Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis for at least 3-6 months is strongly recommended when initiating ULT to prevent acute flares. 1, 3

First-Line Prophylaxis Options

• Low-dose colchicine (0.5-0.6 mg once or twice daily, adjusted for renal function) 3, 5, 4

  • For severe renal impairment (CrCl <30 mL/min): start 0.3 mg/day 2
  • For dialysis patients: 0.3 mg twice weekly 2

• Low-dose NSAIDs with gastroprotection (proton pump inhibitor) if indicated 3, 5, 4

• Low-dose prednisone (≤10 mg/day) for patients with contraindications to both colchicine and NSAIDs 3, 5

Duration of Prophylaxis

• Continue for the greater of:
  • Six months duration, OR 3, 5, 4
  • Three months after achieving target serum urate for patients without tophi, OR 3, 5, 4
  • Six months after achieving target serum urate and resolution of tophi 5, 4

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Management During Acute Flares While on ULT

Continue established ULT without interruption during acute gout attacks 3, 4

• Discontinuing ULT during acute attacks can worsen outcomes and should be avoided 3, 4

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Lifestyle and Non-Pharmacologic Modifications

• Weight loss is recommended for obese patients 3, 5, 4

• Avoid alcoholic drinks (especially beer and spirits) and beverages sweetened with high-fructose corn syrup 3, 5, 4, 8

• Reduce consumption of purine-rich foods (organ meats, shellfish) 8

• Encourage consumption of vegetables and low-fat or nonfat dairy products 8

• Maintain fluid intake sufficient to yield daily urinary output of at least 2 liters 6

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Common Pitfalls and Critical Caveats

• Failure to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 3, 4

• High-dose colchicine regimens cause significant gastrointestinal side effects while low-dose regimens are equally effective 3, 4

• Treatment of gout flares with colchicine is not recommended in patients with renal or hepatic impairment who are already receiving colchicine for prophylaxis 2

• Patient education should include instructions for self-initiation of treatment upon first signs of an acute attack 4