What is the recommended management for gout?

Management of Gout

Gout management requires treating acute flares immediately with colchicine, NSAIDs, or corticosteroids, while simultaneously initiating lifelong urate-lowering therapy with allopurinol to maintain serum uric acid below 6 mg/dL, combined with mandatory 6-month flare prophylaxis and comprehensive patient education. 1, 2

Acute Gout Flare Management

Treat acute flares as early as possible—ideally at the first warning symptoms—with one of three first-line options: 1, 2

• Colchicine: 1 mg loading dose, followed by 0.5 mg one hour later, then 0.5 mg daily 2, 3

  • Reduce dose to 0.5 mg daily or every other day if creatinine clearance is 30-50 mL/min 3
  • For severe renal impairment (CrCl <30 mL/min), use 0.6 mg as a single dose and do not repeat more than once every two weeks 3

• NSAIDs: Use non-selective NSAIDs or COX-2 inhibitors at full anti-inflammatory doses with proton pump inhibitors for gastroprotection if indicated 2, 4

  • Avoid in patients with severe renal impairment, heart failure, or active peptic ulcer disease 5

• Corticosteroids: Oral prednisolone 30-35 mg/day for 3-5 days, or intra-articular injection for monoarticular disease 2, 6

  • Preferred option in patients with contraindications to colchicine and NSAIDs 2

• For refractory cases with frequent flares and contraindications to all standard therapies, consider IL-1 blockers 1, 5

Chronic Gout Management: Urate-Lowering Therapy (ULT)

Initiate ULT early—consider from first presentation and definitively start for: 2, 5

• Recurrent acute attacks (≥2 per year) 5
• Tophi, chronic arthropathy, or renal stones 5
• Young age at presentation (<40 years) 5
• Very high serum uric acid (>8.0 mg/dL or 480 μmol/L) 5
• Comorbidities including renal impairment, hypertension, ischemic heart disease, or heart failure 5

Target Serum Uric Acid Levels

• Standard target: <6 mg/dL (360 μmol/L) maintained lifelong for all patients on ULT 1, 2, 5
• Lower target: <5 mg/dL (300 μmol/L) for severe gout with tophi, chronic arthropathy, or frequent attacks until complete crystal dissolution 1, 2, 5

First-Line ULT: Allopurinol

Allopurinol is the first-line urate-lowering therapy: 1, 2, 7

• Start at 100 mg daily and increase by 100 mg every 2-4 weeks until target serum uric acid is achieved 2, 5, 7
• Maximum dose is 800 mg daily, though doses above 300 mg should be divided 7
• Adjust for renal function: 7
  • CrCl 10-20 mL/min: maximum 200 mg/day 7
  • CrCl <10 mL/min: maximum 100 mg/day 7
  • CrCl <3 mL/min: lengthen interval between doses 7

Second-Line ULT Options

If target serum uric acid cannot be achieved with allopurinol, consider: 1, 2

• Febuxostat (alternative xanthine oxidase inhibitor) 1, 2
• Uricosuric agents (benzbromarone or probenecid) 1, 2
• Combination therapy: xanthine oxidase inhibitor plus uricosuric 1
• Pegloticase for refractory severe debilitating chronic tophaceous gout when all other options have failed 1, 2

Mandatory Flare Prophylaxis During ULT Initiation

Prophylaxis is required for the first 6 months when starting any urate-lowering therapy to prevent mobilization flares: 2, 5, 6

• First-line: Colchicine 0.5-1 mg daily 2, 5, 6

  • Reduce to 0.5 mg daily or every other day if CrCl 30-50 mL/min 6
  • For dialysis patients, use 0.3 mg twice weekly 3

• Alternative: Low-dose NSAIDs with gastroprotection if colchicine is contraindicated or not tolerated 5, 6

• Do not stop ULT during acute flares—continue therapy to maintain target serum uric acid 6

Patient Education and Lifestyle Modifications

Comprehensive patient education is the single most important intervention, increasing adherence to 92% at 12 months: 2, 5

• Weight loss if obese reduces serum uric acid levels significantly 5
• Avoid alcohol, especially beer and spirits (relative risk 1.49 per serving/day for beer) 5
• Eliminate sugar-sweetened drinks and foods high in fructose including orange and apple juice 5
• Limit purine-rich foods such as red meat and seafood (relative risk 1.51 for seafood) 5
• Encourage low-fat dairy products particularly skim milk, which are inversely associated with serum uric acid 5
• Regular exercise should be advised 5
• Educate patients to self-medicate acute flares at first warning symptoms 2

Management of Comorbidities

Systematic screening and management of associated comorbidities is mandatory: 2, 5, 6

• For diuretic-associated gout, substitute the diuretic if possible 6

  • Switch to losartan (modest uricosuric effects) or calcium channel blockers for hypertension 6
  • Consider fenofibrate (has uricosuric properties) for hyperlipidemia 6

• Screen for cardiovascular risk factors including renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidemia, and smoking 5

• Optimize diabetes control as hyperglycemia worsens hyperuricemia 6

• Review all medications for urate-raising effects 6

Critical Pitfalls to Avoid

• Never treat asymptomatic hyperuricemia with ULT 2
• Never stop ULT during an acute flare—this perpetuates the cycle of recurrent attacks 6
• Never initiate ULT without concurrent flare prophylaxis—this dramatically increases the risk of mobilization flares 2, 5, 6
• Never use colchicine to treat acute gout in patients already receiving prophylactic colchicine with CYP3A4 inhibitors 3
• Never underdose allopurinol—titrate to achieve target serum uric acid, not to a predetermined dose 2, 5, 7