What are the treatment options for gout?

Gout Treatment

For acute gout attacks, initiate treatment within 24 hours with NSAIDs, oral corticosteroids, or low-dose colchicine as equally appropriate first-line monotherapy options, selecting based on patient comorbidities and contraindications. 1

Acute Gout Attack Management

Treatment Initiation and General Principles

• Start pharmacologic therapy within 24 hours of symptom onset for optimal pain relief and functional recovery 1
• Continue established urate-lowering therapy (ULT) without interruption during acute attacks—stopping ULT worsens outcomes 1
• Educate patients to self-initiate treatment at first warning symptoms without needing to contact their provider for each attack 1

First-Line Monotherapy Options (Mild-Moderate Attacks: 1-3 Small Joints or 1-2 Large Joints)

NSAIDs:

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 1
• Continue at full dose until the attack completely resolves 1
• Avoid in patients with: chronic kidney disease (CrCl <30 mL/min), congestive heart failure, active peptic ulcer disease, cirrhosis, or concurrent anticoagulation 1
• Add proton pump inhibitor for gastroprotection when indicated 1

Oral Corticosteroids:

• Prednisone 0.5 mg/kg per day (or 30-35 mg/day) for 5-10 days at full dose, then stop OR taper over 7-10 days 1
• Methylprednisolone dose pack is an acceptable alternative 1
• Avoid in patients with: uncontrolled diabetes, active infection, or high infection risk 1
• Particularly useful when NSAIDs and colchicine are contraindicated 1

Low-Dose Colchicine:

• 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg in first hour), then may continue 0.6 mg once or twice daily starting at least 12 hours later 1
• Most effective when started within 12 hours of symptom onset; can be used up to 36 hours 1
• Dose adjustments required for:
  • Moderate-severe renal impairment (CrCl <50 mL/min): reduce to single 0.6 mg dose for acute attack; do not repeat course more than once every 2 weeks 2
  • Dialysis patients: single 0.6 mg dose only; do not repeat more than once every 2 weeks 2
  • Severe hepatic impairment: do not repeat course more than once every 2 weeks 2
  • Drug interactions with strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine): reduce dose or avoid 1, 2

Combination Therapy (Severe/Polyarticular Attacks: ≥4 Joints or Severe Pain)

• Initiate combination therapy for severe polyarticular attacks involving multiple large joints 1
• Acceptable combinations include: 1
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular corticosteroids + any oral agent
• 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 accessible joints (dose varies by joint size) 1
• Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg 1
• Subcutaneous ACTH 25-40 IU with repeat doses as needed 1

Single Joint Involvement:

• Intra-articular corticosteroid injection is highly effective 1

Inadequate Response Definition and Management

• Inadequate response = <20% pain improvement within 24 hours OR <50% improvement after 24 hours 1
• For inadequate response: switch to alternative monotherapy or add second agent from acceptable combinations 1

Adjunctive Non-Pharmacologic Therapy

• Topical ice application to affected joint is appropriate adjunctive measure 1

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT Initiation

• Recurrent acute gout attacks (≥2 per year) 1
• Presence of tophi (palpable or on imaging) 1
• Chronic gouty arthropathy 1
• Radiographic changes of gout 1
• History of urolithiasis 1

Target Serum Urate Level

• Target serum urate <6 mg/dL (357 μmol/L) to achieve dissolution of monosodium urate crystals 1, 3

First-Line ULT Options

Allopurinol:

• Start at 100 mg/day (50 mg/day if CrCl <30 mL/min or stage 4+ CKD) 3
• Titrate gradually to achieve target serum urate 1

Febuxostat:

• Alternative xanthine oxidase inhibitor with similar efficacy to allopurinol 1, 3

Uricosuric Agents (Probenecid, Benzbromarone):

• Reserved for patients with normal renal function, no history of urolithiasis, and allopurinol intolerance 1
• Benzbromarone more effective than allopurinol but may cause hepatotoxicity 1

Anti-Inflammatory Prophylaxis During ULT Initiation

Indications and Timing

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

First-Line Prophylaxis Options

Low-Dose Colchicine (Preferred):

• 0.6 mg once or twice daily (0.5 mg outside US) 1
• Adjust for renal impairment: 0.3 mg once daily for severe CKD; 0.3 mg twice weekly for dialysis patients 1, 2
• Adjust for drug interactions with CYP3A4/P-glycoprotein inhibitors 1

Low-Dose NSAIDs (Alternative):

• Naproxen 250 mg twice daily with proton pump inhibitor where indicated 1

Low-Dose Prednisone/Prednisolone (Second-Line):

• <10 mg/day if colchicine and NSAIDs are contraindicated or not tolerated 1
• Doses >10 mg/day are inappropriate for prophylaxis 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1

• At least 6 months duration, OR
• 3 months after achieving target serum urate (if no tophi detected on exam), OR
• 6 months after achieving target serum urate (if tophi present or previously detected)

Lifestyle Modifications

• Weight loss for obese patients 1, 3
• Avoid alcohol, especially beer and spirits 1, 4
• Avoid beverages sweetened with high-fructose corn syrup 4
• Limit purine-rich foods (organ meats, shellfish) 4
• Encourage consumption of vegetables and low-fat/nonfat dairy products 4
• Review diuretic use—stop if possible, as diuretics increase uric acid levels; consider switching to losartan which increases uric acid excretion 1, 4

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1
• Never discontinue ULT during acute attacks—this worsens disease control 1
• Failure to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 1
• Using high-dose colchicine regimens causes severe gastrointestinal toxicity without additional benefit 1
• Ignoring colchicine dose adjustments for renal impairment or drug interactions risks serious toxicity 1, 2
• Combining NSAIDs with systemic corticosteroids increases gastrointestinal bleeding risk 1
• Inadequate duration of prophylaxis (<6 months) results in breakthrough flares 1