What are the treatment options for gout?

Gout Treatment

For acute gout attacks, initiate corticosteroids, NSAIDs, or low-dose colchicine within 24 hours of symptom onset, with corticosteroids preferred as first-line therapy due to superior safety profile and equivalent efficacy. 1, 2

Acute Gout Attack Management

First-Line Treatment Options (Choose One)

• Corticosteroids are recommended as first-line therapy because they are safer than NSAIDs with fewer adverse effects while maintaining equivalent efficacy for pain reduction. 1

  • Oral prednisolone 30-35 mg daily for 3-5 days is the standard regimen. 1, 2
  • Intra-articular corticosteroid injection is highly effective for single joint involvement (1-2 joints). 2, 3
  • Contraindicated only in patients with systemic fungal infections. 1

• NSAIDs at full anti-inflammatory doses are equally effective when started promptly, with no evidence that indomethacin is superior to other NSAIDs like naproxen or ibuprofen. 1, 2

  • Contraindicated in patients with renal disease, heart failure, cirrhosis, or peptic ulcer disease. 1, 4
  • The timing of initiation matters more than which specific NSAID is chosen. 1

• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is as effective as high-dose regimens with significantly fewer gastrointestinal adverse effects. 1, 2

  • Most effective when started within 12 hours of symptom onset. 2, 3
  • More expensive than corticosteroids or NSAIDs. 1
  • Contraindicated in patients with renal or hepatic impairment using potent CYP3A4 or P-glycoprotein inhibitors. 1, 5
  • For severe renal impairment (CrCl <30 mL/min), reduce to single 0.6 mg dose and do not repeat more than once every two weeks. 5

Treatment Escalation for Severe or Polyarticular Attacks

• For severe pain (≥7/10) or involvement of multiple joints, use combination therapy: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality. 2

Critical Timing Principle

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes—delaying beyond this window significantly reduces effectiveness. 2, 4
• Educate patients to self-initiate treatment at first warning symptoms ("pill in the pocket" approach). 2, 4

Continue Existing Urate-Lowering Therapy

• Do not discontinue established urate-lowering therapy during acute attacks—continue without interruption to avoid worsening outcomes. 2, 4

Long-Term Management and Prevention

Indications for Urate-Lowering Therapy

• Do not initiate urate-lowering therapy after a first gout attack or in patients with infrequent attacks. 1, 2
• Initiate urate-lowering therapy for patients with:
  • Recurrent acute attacks (≥2 per year). 2, 4
  • Tophi (visible or radiographic). 2, 4
  • Chronic gouty arthropathy. 4
  • Radiographic changes of gout. 4

First-Line Urate-Lowering Agents

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options. 2, 3, 4

  • Start allopurinol at ≤100 mg/day and titrate upward every 2-5 weeks to reach target serum urate. 4
  • Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with CKD, Han Chinese, Thai). 4

• Uricosuric agents (probenecid, benzbromarone) are alternatives in patients with normal renal function, no history of urolithiasis, and when xanthine oxidase inhibitors cannot be used. 2, 4

Target Serum Urate Level

• Target serum urate below 6 mg/dL (360 µmol/L). 2, 4

Mandatory Anti-Inflammatory Prophylaxis When Starting Urate-Lowering Therapy

• Anti-inflammatory prophylaxis is strongly recommended whenever urate-lowering therapy is initiated to prevent acute flares that lead to poor medication adherence. 2, 3, 4

• Prophylactic options include:

  • Low-dose colchicine (0.5-0.6 mg once or twice daily). 2, 4
  • Low-dose NSAIDs with gastroprotection if indicated. 2, 4
  • Low-dose prednisone. 2, 3

• Duration of prophylaxis:

  • Continue for at least 6 months. 2, 3
  • OR continue for 3 months after achieving target serum urate if no tophi are present. 2, 4
  • OR continue for 6 months after achieving target serum urate if tophi were present. 2, 4

Non-Pharmacologic Measures

• Weight loss is recommended for obese patients. 2, 4
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup. 2, 4
• Topical ice application is recommended as an adjunctive measure during acute attacks. 2, 4

Common Pitfalls and Critical Caveats

• Delaying treatment beyond 24 hours of symptom onset dramatically reduces effectiveness of all acute therapies. 2, 4

• High-dose colchicine regimens (1.2 mg followed by 0.6 mg hourly for 6 hours) cause significant gastrointestinal toxicity with no additional benefit compared to low-dose regimens. 1, 2

• Discontinuing urate-lowering therapy during acute flares worsens outcomes and should be avoided. 2, 3, 4

• Inadequate duration of prophylaxis when initiating urate-lowering therapy leads to breakthrough flares and poor medication adherence—this is one of the most common management errors. 2, 4

• Drug interactions with colchicine must be carefully considered, particularly with strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporine, clarithromycin) to avoid serious toxicity. 2, 5

• NSAIDs should be avoided in patients with heart failure, peptic ulcer disease, or significant renal disease. 1, 4

• For patients with renal impairment (CrCl <30 mL/min) or on dialysis, colchicine dosing must be reduced: use single 0.6 mg dose for acute attacks and do not repeat more than once every two weeks. 5