What is the diagnosis and treatment for Gout (Gouty Arthritis)?

From the Guidelines

Gout management should prioritize urate-lowering therapy (ULT) for patients with frequent attacks, tophi, or kidney stones, with a target serum urate level of <6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline 1.

Key Recommendations

• For acute gout attacks, use NSAIDs, colchicine, or corticosteroids as first-line treatments, with the goal of reducing inflammation and pain within 24 hours of onset 1.
• For long-term management, consider ULT with allopurinol or febuxostat for patients with frequent attacks, tophi, or kidney stones, with a target serum urate level of <6 mg/dL 1.
• Lifestyle changes, such as limiting alcohol intake, reducing red meat and seafood consumption, maintaining a healthy weight, and staying hydrated, are also important for managing gout 1.

Treatment Options

• NSAIDs: naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days 1.
• Colchicine: 1.2mg at onset, followed by 0.6mg one hour later, then 0.6mg once or twice daily until pain resolves 1.
• Corticosteroids: oral prednisone (30-40mg daily for 3-5 days, then taper) for patients who cannot take NSAIDs or colchicine 1.
• ULT: allopurinol (starting at 100mg daily and gradually increasing) or febuxostat (40-80mg daily) to maintain serum urate levels below 6 mg/dL 1.

From the FDA Drug Label

Gout Flares Prophylaxis of Gout Flares For prophylaxis of gout flares in patients with mild (estimated creatinine clearance [Cl cr] 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine. However, in patients with severe impairment, the starting dose should be 0.3 mg/day and any increase in dose should be done with close monitoring. For the prophylaxis of gout flares in patients undergoing dialysis, the starting doses should be 0.3 mg given twice a week with close monitoring Treatment of Gout Flares For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine However, in patients with severe impairment, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks. For patients with gout flares requiring repeated courses, consideration should be given to alternate therapy For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet). For these patients, the treatment course should not be repeated more than once every two weeks

Gout Treatment:

• Colchicine is used for the prophylaxis and treatment of gout flares.
• The dosage of colchicine may need to be adjusted in patients with renal impairment.
• In patients with severe renal impairment, the starting dose should be 0.3 mg/day and any increase in dose should be done with close monitoring.
• For patients undergoing dialysis, the starting doses should be 0.3 mg given twice a week with close monitoring.
• Indomethacin is also used for the treatment of acute gouty arthritis.
• The clinical efficacy of indomethacin in gout has been demonstrated in clinical trials 2 3.

From the Research

Definition and Causes of Gout

• Gout is a common inflammatory arthritis caused by the deposition of monosodium urate crystals in joints and tissues 4.
• Risk factors for gout include male sex, obesity, hypertension, alcohol intake, diuretic use, and a diet rich in meat and seafood 4.

Symptoms and Diagnosis of Gout

• Gout is characterized by swelling, pain, or tenderness in a peripheral joint or bursa, including the development of a tophus 4.
• Diagnosis of gout can be made using several validated clinical prediction rules, and arthrocentesis should be performed when suspicion for an underlying septic joint is present 4.

Treatment of Acute Gout

• Colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids relieve pain in adults with acute gout episodes 4.
• NSAIDs are commonly used to treat acute gout, and low-certainty evidence suggests that they may improve pain at 24 hours and may have little to no effect on function, inflammation, or adverse events 5, 6.
• Moderate-certainty evidence shows that COXIBs and non-selective NSAIDs are probably equally beneficial with regards to improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs probably increase withdrawals due to adverse events and total adverse events 5, 6.

Urate-Lowering Therapy

• Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended 4.
• Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 4.
• Uricosuric drugs, such as probenecid, increase uric acid excretion, and new drugs in this class will soon become available and are likely to have a role in the treatment of patients who do not respond to other drugs 7.

Management and Prevention

• Management guidelines have emphasized the importance of a therapeutic serum urate target for effective gout management 8.
• Studies have identified the safe and effective dosing strategies for 'old' drugs such as allopurinol and colchicine, and new therapeutic agents have been developed and approved for both urate-lowering therapy and anti-inflammatory treatment of acute flares 8.