What are the treatment options for gout?

Treatment for Gout

For acute gout attacks, initiate treatment within 24 hours using NSAIDs at full anti-inflammatory doses, oral corticosteroids (prednisone 0.5 mg/kg/day), or low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) as equally appropriate first-line monotherapy options, selecting based on patient comorbidities. 1, 2

Acute Gout Attack Management

Treatment Initiation and General Principles

• Start pharmacologic therapy within 24 hours of symptom onset to optimize pain relief and functional recovery 1
• Continue established urate-lowering therapy (ULT) without interruption during acute attacks—stopping ULT worsens outcomes 1
• Apply topical ice as an adjunctive measure to pharmacologic therapy 1, 2

First-Line Monotherapy Options (for mild-moderate attacks involving 1-3 small joints or 1-2 large joints)

NSAIDs:

• Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1, 2
• FDA-approved agents include naproxen, indomethacin, and sulindac, though other NSAIDs at analgesic doses are equally effective 1
• Avoid in patients with chronic kidney disease, congestive heart failure, peptic ulcer disease, or cirrhosis 1, 2, 3

Oral Colchicine:

• Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 1, 2
• Dosing: 1.2 mg followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours) 1, 2, 4
• After initial dosing, can continue 0.6 mg twice daily starting at least 12 hours later until attack resolves 1
• Adjust dose for renal impairment and drug interactions (particularly with P-glycoprotein/CYP3A4 inhibitors like clarithromycin or cyclosporine) 1, 4
• For severe renal impairment (CrCl <30 mL/min), treatment course should not be repeated more than once every two weeks 4

Oral Corticosteroids:

• Prednisone 0.5 mg/kg/day for 5-10 days at full dose, then stop OR taper over 7-10 days 1, 2
• Alternative: 30-35 mg/day for 3-5 days 3
• Particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2
• Avoid in patients with diabetes, active infection, or high infection risk 1

Intra-articular Corticosteroid Injection:

• Highly effective for single joint involvement 1, 2, 5
• Dose varies by joint size 1

Combination Therapy (for severe pain ≥7/10 or polyarticular involvement ≥4 joints)

• Combination therapy is appropriate for severe presentations 1
• Acceptable combinations include:
  • Colchicine + NSAIDs 1
  • Oral corticosteroids + colchicine 1
  • Intra-articular steroids with any other modality 1
• Do not combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1

Special Populations

NPO (Nothing by Mouth) Patients:

• Intra-articular corticosteroid injection for 1-2 affected joints 1
• Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg OR subcutaneous ACTH 25-40 IU for multiple joint involvement 1

Inadequate Response Management

• Inadequate response defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours 1, 2
• For inadequate response to monotherapy, add a second appropriate agent or switch to combination therapy 1

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

• Recurrent acute attacks, tophi, chronic gouty arthropathy, or radiographic changes of gout 1, 2, 5
• History of nephrolithiasis 6

First-Line ULT Options

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line agents 1, 2, 3
• Target serum urate level: <6 mg/dL (357 μmol/L) 1, 2, 5
• Allopurinol starting dose: ≤100 mg/day (50 mg/day in stage 4 or worse CKD), then titrate to achieve target 3

Alternative ULT Options

• Uricosuric agents (probenecid, benzbromarone) for patients with normal renal function, no history of urolithiasis, and who are allopurinol-intolerant 1, 5, 7
• Benzbromarone is more effective than allopurinol but may be hepatotoxic 1

Anti-Inflammatory Prophylaxis During ULT Initiation

Indications and Timing

• Mandatory for all patients when initiating ULT to prevent acute flares 1, 2
• Initiate prophylaxis with or just prior to starting ULT 1, 3

First-Line Prophylaxis Options

Low-Dose Colchicine (preferred):

• 0.5-0.6 mg once or twice daily 1, 2
• Adjust for renal impairment and drug interactions 1, 4

Low-Dose NSAIDs (alternative):

• Example: naproxen 250 mg twice daily 1, 2
• Add proton pump inhibitor where indicated for gastroprotection 1, 2

Low-Dose Prednisone/Prednisolone (second-line):

• <10 mg/day 1, 2
• Use only if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 2

• At least 6 months duration, OR
• 3 months after achieving target serum urate (for patients without tophi on physical exam), OR
• 6 months after achieving target serum urate (for patients with tophi detected on physical exam)

Non-Pharmacologic Measures

• Weight loss for obese patients 1, 2, 5
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 2, 5, 6
• Encourage consumption of vegetables and low-fat/nonfat dairy products 6
• Reduce purine-rich foods (organ meats, shellfish) 6

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 5
• Never discontinue ULT during acute attacks—this worsens outcomes and prolongs recovery 1
• Failure to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 1, 2
• High-dose colchicine regimens (>1.8 mg in 12 hours) cause significant gastrointestinal toxicity without additional benefit 1, 5
• NSAIDs contraindicated in heart failure, peptic ulcer disease, and significant renal disease 1, 2
• Colchicine drug interactions with P-glycoprotein/CYP3A4 inhibitors can cause life-threatening toxicity 1, 5, 4
• Inadequate prophylaxis duration (<6 months or before achieving target urate) increases breakthrough flare risk 1, 5