What is the recommended management for gout?

Management of Gout

For acute gout flares, use oral colchicine (1.2 mg immediately followed by 0.6 mg one hour later), NSAIDs, or glucocorticoids as first-line therapy, with the choice driven by patient comorbidities; for chronic management, initiate allopurinol starting at 100 mg daily (lower in chronic kidney disease) and titrate to achieve a serum uric acid target of <6 mg/dL. 1

Acute Gout Flare Management

First-Line Anti-Inflammatory Therapy

The 2020 American College of Rheumatology strongly recommends three equally effective first-line options 1:

• Oral colchicine: FDA-approved dosing is 1.2 mg immediately followed by 0.6 mg one hour later, with ongoing therapy until flare resolves 1, 2

  • Low-dose colchicine is strongly preferred over high-dose due to similar efficacy with fewer adverse effects 1
  • Do not exceed 1.8 mg in the first hour to avoid gastrointestinal toxicity 3

• NSAIDs: Any NSAID at full anti-inflammatory dose is appropriate 1

  • Contraindicated in significant renal impairment, heart failure, or cirrhosis 3
  • The key to success is early initiation, not which specific NSAID is chosen 4

• Glucocorticoids: Oral prednisone 30-35 mg daily for 3-5 days 3

  • Intraarticular or intramuscular routes are strongly recommended when oral dosing is not possible 1
  • Particularly useful in patients with contraindications to NSAIDs or colchicine 1

Second-Line Therapy

• IL-1 inhibitors (e.g., canakinumab, anakinra) are conditionally recommended only when conventional therapies are poorly tolerated or contraindicated 1
  • Cost and access remain significant barriers 1

Adjunctive Measures

• Topical ice is conditionally recommended as adjuvant treatment 1
• Early intervention with a "medication-in-pocket" strategy is preferred for patients who can identify early flare signs 1

Critical Caveat: Ruling Out Septic Arthritis

When podagra appears infected (fever >38.5°C, severe inflammation), perform urgent arthrocentesis to rule out septic arthritis before initiating anti-inflammatory therapy 3. The two conditions can coexist, and septic arthritis requires immediate IV antibiotics 3.

Chronic Gout Management: Urate-Lowering Therapy (ULT)

Indications for ULT

Strongly recommend initiating ULT for patients with 1:

• Tophaceous gout
• Radiographic damage due to gout
• Frequent gout flares (≥2 per year)
• Chronic kidney disease
• History of urolithiasis

First-Line ULT: Allopurinol

Allopurinol is the preferred first-line agent, including for patients with moderate-to-severe chronic kidney disease (stage ≥3) 1, 5:

• Starting dose: ≤100 mg daily (lower in CKD) 1

  • For CrCl 10-20 mL/min: 200 mg daily maximum 5
  • For CrCl <10 mL/min: 100 mg daily maximum 5
  • For dialysis patients: Consider lengthening intervals between doses 5

• Dose titration: Increase by 100 mg every 2-4 weeks (weekly intervals acceptable) until target serum uric acid is achieved 1, 5

  • Average maintenance dose: 200-300 mg daily for mild gout, 400-600 mg daily for moderately severe tophaceous gout 5
  • Maximum dose: 800 mg daily 5

• Target serum uric acid: <6 mg/dL (360 μmol/L) 1

  • For severe gout with tophi, chronic arthropathy, or frequent attacks: target <5 mg/dL (300 μmol/L) until crystal dissolution 1
  • Do not maintain serum uric acid <3 mg/dL long-term 1

Alternative ULT Options

If allopurinol target cannot be reached at maximum appropriate dose or if allopurinol is not tolerated 1:

• Febuxostat: Start <40 mg daily and titrate upward 1

  • Clinically equivalent to allopurinol 6

• Uricosuric agents (probenecid, benzbromarone): Reserved for patients with normal renal function, no history of nephrolithiasis, and documented urate underexcretion 1

  • Benzbromarone is more effective than allopurinol but may be hepatotoxic 1
  • Can be combined with allopurinol if monotherapy insufficient 1

• Pegloticase: Only for crystal-proven severe debilitating chronic tophaceous gout with poor quality of life when maximal doses of other agents (including combinations) have failed 1

Flare Prophylaxis During ULT Initiation

Strongly recommend concomitant anti-inflammatory prophylaxis for at least 3-6 months when starting ULT 1:

• Colchicine 0.5-1 mg daily is the preferred prophylactic agent 1, 3
• Alternative: Low-dose NSAID with gastroprotection if indicated 1
• Continue prophylaxis for at least 6 months, or until serum uric acid is at target and patient has been flare-free for several months 1, 7

Monitoring Strategy

• Treat-to-target approach: Titrate ULT dose guided by serial serum urate measurements 1
• Monitor serum uric acid regularly during dose titration 1
• Maintain target serum uric acid lifelong 1

Lifestyle Modifications

The following are conditionally recommended for all patients with gout, regardless of disease activity 1:

• Weight loss if overweight/obese (no specific program endorsed) 1

  • Weight loss reduces serum uric acid levels 1

• Limit alcohol intake, especially beer and spirits 1

  • Wine consumption does not significantly increase serum uric acid 1

• Limit purine intake: Reduce consumption of organ meats, shellfish, and other purine-rich foods 1, 7

• Limit high-fructose corn syrup intake and sugar-sweetened beverages 1

• Encourage low-fat dairy products: Inversely associated with uric acid levels 1

• Regular physical activity may decrease excess mortality associated with hyperuricemia 1

• Coffee and cherry consumption may be protective 1

Management of Comorbidities

Address associated conditions as part of comprehensive gout management 1:

• Hypertension: Consider losartan (increases uric acid excretion) or calcium channel blockers instead of diuretics 1
• Hyperlipidemia: Consider fenofibrate (reduces serum uric acid) or statins 1
• Diuretic use: Discontinue loop or thiazide diuretics if possible, as they increase gout risk 1

Common Pitfalls to Avoid

• Do not treat asymptomatic hyperuricemia with pharmacologic therapy 8
• Do not start or stop ULT during an acute flare; continue existing ULT and treat the flare separately 1
• Do not use high-dose colchicine for acute flares due to increased toxicity without improved efficacy 1
• Do not initiate ULT without concurrent flare prophylaxis, as this increases risk of precipitating acute attacks 1, 9
• Do not underdose allopurinol in CKD; adjust starting dose but titrate to achieve target serum uric acid 1