What are the treatment options for gout?

Treatment of Gout

Acute Gout Attack Management

For acute gout attacks, initiate treatment within 24 hours with NSAIDs, oral colchicine, or corticosteroids as first-line monotherapy options, selecting based on comorbidities and contraindications. 1

Treatment Selection Based on Attack Severity

Mild to Moderate Attacks (≤6/10 pain, 1-3 small joints or 1-2 large joints):

• Choose one of the following monotherapy options 1:
  • NSAIDs at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) continued until complete resolution 1, 2
  • Low-dose colchicine: 1.2 mg followed by 0.6 mg one hour later (most effective within 12 hours, acceptable up to 36 hours of symptom onset) 1, 2, 3
  • Oral corticosteroids: Prednisone 0.5 mg/kg/day for 5-10 days, then stop or taper 1, 2
  • Intra-articular corticosteroid injection for single accessible joint involvement 1

Severe or Polyarticular Attacks (≥7/10 pain or ≥4 joints):

• Combination therapy is appropriate 1:
  • Colchicine + NSAIDs 1
  • Oral corticosteroids + colchicine 1
  • Intra-articular steroids with any other modality 1

Critical Drug Selection Considerations

Avoid NSAIDs in patients with: 1, 2, 4

• Chronic kidney disease (CKD stage 3 or worse)
• Congestive heart failure
• Peptic ulcer disease or GI bleeding history
• Cirrhosis

Avoid corticosteroids in patients with: 1, 5

• Poorly controlled diabetes
• Active infection or high infection risk

Colchicine dose adjustments required for: 1, 3

• Severe renal impairment (CrCl <30 mL/min): Single 0.6 mg dose for acute treatment, repeat no more than once every 2 weeks 3
• Dialysis patients: Single 0.6 mg dose, repeat no more than once every 2 weeks 3
• Severe hepatic impairment: Treatment course repeated no more than once every 2 weeks 3
• Drug interactions: Reduce dose with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine) 1, 4

NPO (Nothing by Mouth) Patients

For hospitalized patients unable to take oral medications 1:

• 1-2 affected joints: Intra-articular corticosteroid injection (dose varies by joint size) 1
• Multiple joints: IV/IM methylprednisolone 0.5-2.0 mg/kg OR subcutaneous ACTH 25-40 IU 1

Inadequate Response Management

Define inadequate response as: <20% pain improvement within 24 hours OR <50% improvement after 24 hours 1, 2

If inadequate response occurs: 1, 4

• Switch to alternative monotherapy agent
• Add a second appropriate agent from different class

Adjunctive Measures

• Topical ice application to affected joint 1, 2, 4
• Continue established urate-lowering therapy without interruption during acute attacks 1, 4

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Long-Term Urate-Lowering Therapy (ULT)

Initiate ULT in patients with: 1, 2, 5, 4

• Recurrent acute gout attacks (≥2 per year)
• Tophi (palpable or on imaging)
• Chronic gouty arthropathy
• Radiographic changes of gout
• History of urolithiasis

Target serum urate level: <6 mg/dL (357 μmol/L) 1, 2, 5, 4

First-Line ULT Options

Xanthine oxidase inhibitors are first-line: 1, 2, 5

• Allopurinol: Start at ≤100 mg/day (50 mg/day if CKD stage 4 or worse), titrate to achieve target 5
• Febuxostat: Alternative with similar efficacy 1, 6

Uricosuric agents (probenecid, benzbromarone): Reserved for patients with normal renal function, no urolithiasis history, or allopurinol intolerance 1, 7, 8

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Anti-Inflammatory Prophylaxis During ULT Initiation

Prophylaxis is mandatory when starting or adjusting ULT to prevent acute flares. 1, 2, 5

Prophylaxis Medication Options

First-line (in order of preference): 1, 2, 5

• Low-dose colchicine: 0.6 mg once or twice daily (0.5 mg outside US), adjusted for renal function and drug interactions 1, 2, 5
• Low-dose NSAIDs: Naproxen 250 mg twice daily with proton pump inhibitor if indicated 1, 2, 5

Second-line (if colchicine and NSAIDs contraindicated/not tolerated): 1, 5

• Low-dose prednisone/prednisolone: <10 mg/day 1

Duration of Prophylaxis

Continue prophylaxis for the GREATER of: 1, 2, 5, 4

• At least 6 months from ULT initiation 1
• OR 3 months after achieving target serum urate (if no tophi present) 1, 4
• OR 6 months after achieving target serum urate (if tophi were present and have resolved) 1, 4

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Lifestyle and Non-Pharmacologic Modifications

Dietary recommendations: 1, 5, 4, 9

• Weight loss if obese 1, 2, 5, 4
• Avoid alcohol (especially beer and spirits) 1, 5, 4, 9
• Avoid beverages with high-fructose corn syrup 2, 4, 9
• Limit purine-rich foods (organ meats, shellfish) 9
• Encourage low-fat dairy products and vegetables 9

Medication review: 1

• Discontinue diuretics if medically feasible 1
• Consider losartan (increases uric acid excretion) if antihypertensive needed 9, 8

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Critical Pitfalls to Avoid

Timing errors: 1, 2, 4

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 4
• Colchicine loses efficacy if started >36 hours after symptom onset 1

ULT management errors: 1, 4

• Never discontinue ULT during acute flares - this worsens outcomes 1, 4
• Failure to provide prophylaxis when initiating ULT leads to breakthrough flares and medication non-adherence 1, 2, 4

Dosing errors: 1, 2, 4, 3

• High-dose colchicine regimens (previously used) cause severe GI toxicity without additional benefit 1, 2, 4
• The FDA-approved low-dose colchicine regimen (1.2 mg then 0.6 mg one hour later) is equally effective with fewer adverse effects 1, 2, 3

Drug interaction oversight: 1, 4, 3

• Colchicine with strong CYP3A4/P-glycoprotein inhibitors can cause fatal toxicity 1, 4
• Mandatory dose reduction or avoidance with clarithromycin, cyclosporine, or similar agents 1, 3

Patient education gaps: 1, 4

• Educate patients to self-initiate treatment at first warning symptoms ("pill in pocket" approach) 4
• Provide clear instructions on when to seek medical attention versus self-treatment 1