What is the management for gouty arthritis?

Management of Gouty Arthritis

Acute gouty arthritis should be treated with pharmacologic therapy initiated within 24 hours of symptom onset using NSAIDs, colchicine, or corticosteroids as first-line monotherapy options, with combination therapy reserved for severe or polyarticular attacks. 1

Acute Attack Management

Timing and General Principles

• Initiate treatment within 24 hours of attack onset for optimal therapeutic response, as delays significantly reduce treatment effectiveness 1, 2, 3
• Continue existing urate-lowering therapy (ULT) without interruption during acute attacks, as stopping ULT can worsen and prolong the attack 1, 4, 3
• Colchicine is only effective if started within 36 hours of symptom onset 1, 3

First-Line Monotherapy Options (Choose One Based on Contraindications)

NSAIDs:

• Use full FDA-approved anti-inflammatory doses until complete attack resolution 1, 2
• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 1, 2, 5
• Continue at full dose until symptoms completely resolve, typically 5-14 days 2
• Avoid in patients with chronic kidney disease (CKD) due to acute renal toxicity risk 6

Colchicine:

• Loading dose: 1.2 mg followed by 0.6 mg one hour later 1, 2, 3
• Then start prophylaxis dosing (0.6 mg once or twice daily) beginning 12 hours after loading dose, continuing until attack resolves 1, 2
• Requires dose adjustment in renal impairment and for drug interactions 1, 6
• Low-dose regimen has similar efficacy to high-dose with significantly fewer gastrointestinal side effects 4, 3

Corticosteroids:

• Oral prednisone: 0.5 mg/kg per day for 5-10 days at full dose then stop, OR 2-5 days at full dose then taper over 7-10 days 1
• Intra-articular: Dose varies by joint size, can be combined with oral therapy 1
• Intramuscular: Triamcinolone acetonide 60 mg, then oral prednisone as above 1
• Preferred option in patients with renal impairment or contraindications to NSAIDs/colchicine 3

Combination Therapy for Severe/Polyarticular Attacks

• Initial combination therapy is appropriate for severe attacks involving multiple large joints or polyarticular arthritis (≥4 joints or 3 separate large joints) 1, 2

Recommended combinations:

1. Colchicine + NSAIDs 1
2. Oral corticosteroids + colchicine 1
3. Intra-articular steroids with any other modality 1

Critical caveat: Do NOT combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1, 3

Anti-Inflammatory Prophylaxis (When Initiating ULT)

Indications and Timing

• Initiate prophylaxis with or just prior to starting urate-lowering therapy to prevent acute flares triggered by crystal mobilization 1, 4, 7
• Prophylaxis is recommended for all gout patients when pharmacologic ULT is initiated 1

First-Line Prophylaxis Options

Low-dose colchicine (preferred):

• 0.6 mg once or twice daily (0.5 mg outside US) 1, 2, 4
• Adjust dose in chronic kidney disease and for drug interactions 1

Low-dose NSAIDs (alternative):

• Example: Naproxen 250 mg twice daily 1
• Add proton pump inhibitor where indicated 1, 4

Second-line (if colchicine and NSAIDs contraindicated):

• Low-dose prednisone or prednisolone (<10 mg/day) 1

Duration of Prophylaxis

Choose the GREATER of:

• At least 6 months, OR 1, 2, 4
• 3 months after achieving target serum urate (if no tophi detected) 1
• 6 months after achieving target serum urate (if tophi present) 1

Long-Term Urate-Lowering Therapy

Indications for ULT

• Patients with tophi, chronic gouty arthropathy, or recurrent attacks 4
• Goal: maintain serum uric acid below 6 mg/dL 4, 7

ULT Options

Allopurinol (first-line):

• Start with 100 mg daily, increase weekly by 100 mg increments until serum uric acid ≤6 mg/dL (maximum 800 mg/day) 7
• Lower doses required in decreased renal function 7
• Must provide colchicine prophylaxis when initiating to suppress acute attacks 7

Febuxostat (alternative):

• Particularly useful in allopurinol intolerance or contraindications 4
• May be used in mild to moderate renal impairment, but insufficient data for CrCl <30 mL/min 6

Uricosuric agents (probenecid):

• Indicated for hyperuricemia associated with gout and gouty arthritis 8
• Preferred in allopurinol-allergic patients and underexcretors with normal renal function and no urolithiasis history 9

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2, 3
• Stopping ULT during acute attacks worsens and prolongs the attack 4, 3
• Using high-dose colchicine regimens causes significant gastrointestinal side effects without additional benefit 4, 3
• Failing to provide prophylaxis when initiating ULT leads to increased flare frequency 4, 3
• Ignoring drug interactions with colchicine can lead to serious toxicity 3
• Using NSAIDs in patients with CKD can cause acute renal toxicity or worsen kidney function 6
• Combining NSAIDs with systemic corticosteroids increases gastrointestinal toxicity risk 3

Special Considerations for Comorbidities

• Metabolic syndrome, hypertension, cardiovascular disease, diabetes, and CKD are highly prevalent in gouty arthritis patients 6
• NSAIDs should be avoided in CKD patients 6
• Colchicine and ULT require dosage adjustments in renal impairment 6
• Multiple drug-drug interactions may alter serum uric acid levels in patients with polypharmacy 6