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, 2

Acute Attack Management

Timing and General Principles

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

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

NSAIDs:

• Use full FDA-approved anti-inflammatory doses until complete attack resolution 1, 2, 3
• FDA-approved options for acute gout include naproxen, indomethacin, and sulindac 1, 2, 3
• Continue at full dose until the gouty attack has completely resolved 1
• Consider proton pump inhibitor co-administration where gastrointestinal risk factors exist 1

Colchicine:

• Loading dose: 1.2 mg followed by 0.6 mg one hour later 1, 2, 3
• Then begin prophylaxis dosing (0.6 mg once or twice daily) starting 12 hours after loading dose, continuing until attack resolves 1, 2
• Critical caveat: Adjust doses downward in the presence of significant drug interactions and moderate to severe renal or hepatic impairment 1
• If patient is already on prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid) rather than additional colchicine 1

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 for 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

Severe or Polyarticular Attacks (≥4 joints or multiple large joints)

Combination therapy is appropriate for initial treatment: 1

• Colchicine + NSAIDs (full doses) 1
• Oral corticosteroids + colchicine 1
• Intra-articular steroids with any other modality 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 1, 3

Inadequate Response to Monotherapy

• Add a second appropriate agent if <20% improvement in pain at 24 hours or <50% improvement at 48 hours 1
• Use acceptable combination approaches listed above 1

Anti-Inflammatory Prophylaxis During Urate-Lowering Therapy

When to Initiate

• Start prophylaxis with or just prior to initiating any ULT to prevent acute flares triggered by crystal mobilization 1, 2, 4, 5
• Prophylaxis is recommended for all gout patients when pharmacologic ULT is initiated 1

First-Line Prophylaxis Options

Low-dose colchicine (preferred): 1, 2

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

Low-dose NSAIDs (alternative first-line): 1

• Example: Naproxen 250 mg twice daily 1
• Add proton pump inhibitor where gastrointestinal risk factors exist 1

Second-Line Prophylaxis

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

• Use only if colchicine and NSAIDs are both contraindicated, not tolerated, or ineffective 1

Duration of Prophylaxis

Continue for the greater of: 1, 2

• At least 6 months, OR 1, 2
• 3 months after achieving target serum urate (if no tophi detected on physical exam) 1, 2
• 6 months after achieving target serum urate (if one or more tophi detected) 1, 2

Long-Term Urate-Lowering Therapy

Indications for ULT

• Recurrent gout attacks, tophi, chronic gouty arthropathy, or urate nephropathy 4, 5
• Goal: maintain serum uric acid below 6 mg/dL 4, 5

First-Line ULT Options

Allopurinol (preferred): 4, 5

• Start with low dose (100 mg daily) and increase at weekly intervals by 100 mg until serum uric acid ≤6 mg/dL is attained, without exceeding 800 mg per day 5
• Lower doses required in patients with decreased renal function 5
• Must provide prophylactic colchicine or anti-inflammatory agents when initiating to suppress gouty attacks 5

Febuxostat (alternative): 4

• Particularly useful in patients with allopurinol intolerance or contraindications 4

Uricosuric Agents

• Probenecid is indicated for hyperuricemia associated with gout and gouty arthritis 6
• Consider in allopurinol-allergic patients with normal renal function and no history of urolithiasis 7

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours significantly reduces effectiveness of all agents 2, 3
• Stopping ULT during acute flares worsens and prolongs attacks—continue without interruption 1, 4, 3
• Using high-dose colchicine regimens causes significant gastrointestinal side effects without additional benefit over low-dose regimens 4, 3
• Failing to provide prophylaxis when initiating ULT leads to increased flare frequency during the first months of therapy 1, 2, 4
• Ignoring drug interactions with colchicine can lead to serious toxicity, particularly with CYP3A4 inhibitors and P-glycoprotein inhibitors 3
• Combining NSAIDs with systemic corticosteroids increases gastrointestinal toxicity risk 1, 3
• Starting allopurinol at high doses increases risk of acute flares—titrate slowly from 100 mg daily 5
• Inadequate dose adjustment in renal impairment for both colchicine and allopurinol can lead to toxicity 1, 5