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 outcomes, as early treatment significantly improves pain relief and functional recovery 1
• Continue established urate-lowering therapy (ULT) without interruption during acute attacks—do not stop allopurinol or febuxostat when a flare occurs 1
• Apply topical ice to the affected joint as an adjunctive measure to pharmacologic therapy 1

First-Line Monotherapy Options (Mild-Moderate Attacks)

For attacks involving 1-3 small joints or 1-2 large joints with pain ≤6/10:

NSAIDs

• Use full anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) and continue until the attack completely resolves 1
• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac 1
• Avoid NSAIDs in patients with:
  • Chronic kidney disease (CrCl <30 mL/min) 1
  • Congestive heart failure 1
  • Active peptic ulcer disease 1
  • Cirrhosis 1
• Add proton pump inhibitor therapy when indicated for gastroprotection 1

Oral Corticosteroids

• Prednisone 0.5 mg/kg per day (or 30-35 mg/day) for 5-10 days, either at full dose then stop, or taper over 7-10 days 1
• Particularly useful for patients with contraindications to NSAIDs or colchicine 1
• Avoid in patients with:
  • Uncontrolled diabetes 1
  • Active infection or high infection risk 1

Low-Dose Colchicine

• 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg in first 12 hours), then may continue 0.6 mg once or twice daily starting 12 hours later until attack resolves 1, 2
• Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 1
• Low-dose regimen is equally effective as high-dose with significantly fewer gastrointestinal side effects 1
• Dose adjustments required for:
  • Severe renal impairment (CrCl <30 mL/min): single 0.6 mg dose, do not repeat for 2 weeks 2
  • Dialysis patients: single 0.6 mg dose, do not repeat for 2 weeks 2
  • Severe hepatic impairment: do not repeat treatment course for 2 weeks 2
• Do not use colchicine for acute attacks in patients already on colchicine prophylaxis—choose alternative therapy 2

Combination Therapy (Severe/Polyarticular Attacks)

For severe pain (≥7/10) or polyarticular involvement (≥4 joints):

• Appropriate combination options 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 as alternative 1
• Subcutaneous ACTH 25-40 IU as alternative 1

Inadequate Response to Initial Therapy

• Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours 1
• Switch to another monotherapy agent or add a second appropriate agent 1

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT Initiation

• Recurrent acute gout attacks (≥2 attacks per year) 1, 3
• Presence of tophi (palpable or on imaging) 1, 3
• Chronic gouty arthropathy 1, 3
• Radiographic changes of gout 1, 3
• History of urolithiasis 1

First-Line ULT Options

• Allopurinol (xanthine oxidase inhibitor):
  • 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 <6 mg/dL 1, 3
• Febuxostat (xanthine oxidase inhibitor) as alternative 1, 3
• Target serum urate level: <6 mg/dL (357 μmol/L) 1, 3

Uricosuric Agents (Alternative Options)

• Probenecid or benzbromarone for patients with:
  • Normal renal function 1
  • No history of urolithiasis 1
  • Allopurinol intolerance or allergy 1
• Benzbromarone is more effective than allopurinol but carries hepatotoxicity risk 1

Anti-Inflammatory Prophylaxis During ULT Initiation

Indications and Timing

• Initiate prophylaxis with or just prior to starting ULT in all patients 1, 3
• Prophylaxis prevents acute flares triggered by fluctuating urate levels during ULT initiation 1

First-Line Prophylaxis Options

Low-Dose Colchicine (Preferred)

• 0.6 mg once or twice daily (0.5 mg outside US) 1, 3
• Dose adjustments for renal impairment: 1, 2
  • Mild-moderate impairment (CrCl 30-80 mL/min): monitor closely, may not require adjustment
  • Severe impairment (CrCl <30 mL/min): start 0.3 mg/day
  • Dialysis: 0.3 mg twice weekly
• Adjust dose for drug interactions with P-glycoprotein/CYP3A4 inhibitors (e.g., clarithromycin, cyclosporine) 1, 2

Low-Dose NSAIDs (Alternative)

• Naproxen 250 mg twice daily with proton pump inhibitor if indicated 1, 3
• Contraindicated in patients with renal disease, heart failure, or peptic ulcer disease 1

Low-Dose Prednisone (Second-Line)

• <10 mg/day for patients with contraindications to both colchicine and NSAIDs 1, 3
• Doses >10 mg/day are inappropriate for prophylaxis 1
• Monitor closely for corticosteroid-related adverse effects, especially in diabetic patients 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 3

• At least 6 months from ULT initiation, OR
• 3 months after achieving target serum urate (<6 mg/dL) in patients without tophi, OR
• 6 months after achieving target serum urate in patients with tophi (after tophi resolution)

Lifestyle Modifications

• Weight loss for obese patients 1, 3
• Avoid alcohol, especially beer and spirits 1, 3
• Avoid beverages sweetened with high-fructose corn syrup 1, 3
• Limit purine-rich foods (organ meats, shellfish) 4
• Encourage consumption of vegetables and low-fat/nonfat dairy products 4
• Consider discontinuing diuretics if medically feasible, as they increase uric acid levels 1

Common Pitfalls and How to Avoid Them

• Delaying treatment beyond 24 hours significantly reduces effectiveness—educate patients on self-medicating at first warning symptoms ("pill in pocket" approach) 1
• Stopping ULT during acute attacks worsens outcomes and prolongs disease activity—always continue allopurinol/febuxostat 1
• Using high-dose colchicine regimens causes severe gastrointestinal toxicity without additional benefit—always use low-dose regimen 1
• Failing to provide prophylaxis when starting ULT leads to acute flares and poor medication adherence—mandatory prophylaxis for all patients 1
• Inadequate duration of prophylaxis results in breakthrough flares—continue for minimum 6 months or longer based on clinical indicators 1
• Ignoring colchicine drug interactions can cause life-threatening toxicity—always check for P-glycoprotein/CYP3A4 inhibitors 1, 2
• Using NSAIDs in patients with renal disease risks acute kidney injury—choose corticosteroids instead 1