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 (oral, intraarticular, or intramuscular) as first-line therapy, with the choice driven by patient comorbidities; for chronic management, initiate urate-lowering therapy with allopurinol starting at 100 mg/day (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 for acute flares 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, or intraarticular/intramuscular injection 1, 3

  • Parenteral glucocorticoids are strongly recommended when oral dosing is not possible 1

Patient-Specific Selection Algorithm

Choose therapy based on these comorbidities 1, 3:

• Renal impairment (CrCl <30 mL/min): Glucocorticoids preferred; avoid NSAIDs 3
• Heart failure or cirrhosis: Glucocorticoids preferred; avoid NSAIDs 3
• Multiple comorbidities: Glucocorticoids often safest option 1
• Otherwise healthy patients: Any of the three options acceptable 1

Second-Line Therapy

• IL-1 inhibitors (canakinumab, anakinra) are conditionally recommended only when first-line agents are contraindicated or poorly tolerated 1
  • Cost and access issues significantly limit use 1

Adjunctive Therapy

• Topical ice is conditionally recommended as adjuvant treatment 1

Early Intervention Strategy

• Provide patients with "medication-in-pocket" strategy to self-initiate treatment at first sign of flare 1
  • Early treatment is critical for optimal outcomes 1, 4

Urate-Lowering Therapy (ULT)

Indications for Initiating ULT

Strongly recommend ULT for patients with 1:

• Tophaceous gout
• Radiographic damage due to gout
• Frequent gout flares (≥2 per year)

Conditionally recommend ULT for 1:

• First gout flare with chronic kidney disease stage ≥2
• Serum uric acid >9 mg/dL
• Urolithiasis

First-Line ULT: Allopurinol

Allopurinol is strongly recommended as first-line ULT, including for patients with moderate-to-severe chronic kidney disease (stage ≥3) 1:

• Starting dose: ≤100 mg/day (lower in CKD) 1, 5

  • CrCl 50-80 mL/min: Start 100 mg/day 2
  • CrCl 30-50 mL/min: Start 100 mg/day with close monitoring 2
  • CrCl 10-20 mL/min: Maximum 200 mg/day 5
  • CrCl <10 mL/min: Maximum 100 mg/day 5
  • Dialysis: 100 mg/day with extended dosing intervals 5

• Dose titration: Increase by 100 mg every 2-4 weeks until target serum uric acid achieved 1, 5

  • Maximum recommended dose: 800 mg/day 5

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

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

Alternative ULT Options

If allopurinol target not achieved at maximum appropriate dose or if intolerant 1:

• Febuxostat: Start <40 mg/day and titrate 1

  • Clinically equivalent to allopurinol 6

• Uricosuric agents (probenecid, benzbromarone): For underexcretors with normal renal function and no nephrolithiasis history 4

  • Can be combined with allopurinol 1

• Pegloticase: Reserved for severe debilitating chronic tophaceous gout when other therapies fail at maximal doses 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 preferred prophylactic agent 1, 3
• Alternative: Low-dose NSAID with gastroprotection if indicated 1
• Continue prophylaxis for at least 6 months after achieving target serum uric acid, or longer if tophi present 7, 8

Monitoring Strategy

• Treat-to-target approach: Titrate ULT dose based on serial serum uric acid measurements 1
• Maintain serum uric acid <6 mg/dL lifelong 1
• Monitor serum uric acid every 2-4 weeks during titration 1

Lifestyle Modifications

Conditionally recommend for all gout patients regardless of disease activity 1:

• Weight loss if overweight/obese 1

  • Weight loss reduces serum uric acid levels 1

• Limit alcohol intake, especially beer and spirits 1

  • Wine consumption does not significantly increase uric acid 1

• Limit purine intake: Reduce organ meats, shellfish, and red meat 1

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

• Encourage low-fat dairy products 1, 7

  • Inversely associated with serum uric acid 1

• Regular physical activity 1

Management of Comorbidities and Medications

Address associated conditions as part of comprehensive gout management 1:

• Diuretics: Discontinue if possible when gout develops 1
• Hypertension: Consider losartan (uricosuric effect) or calcium channel blockers over diuretics 1
• Hyperlipidemia: Consider fenofibrate (reduces serum uric acid) or statins 1
• Metabolic syndrome components: Treat hyperlipidemia, hypertension, hyperglycemia, and obesity 1

Critical Pitfalls to Avoid

• Do not start or stop ULT during an acute flare 1

  • Treat the flare first, then initiate ULT after resolution 1

• Do not use high-dose colchicine (>1.8 mg in first hour) due to increased toxicity without added benefit 1, 3

• Do not start allopurinol at high doses without titration, as this increases flare risk 1, 5

• Do not initiate ULT without concurrent flare prophylaxis for at least 3-6 months 1, 8

• Do not use colchicine for acute flares in patients already on prophylactic colchicine with CYP3A4 inhibitors 2

• Adjust colchicine and allopurinol doses in renal impairment to prevent toxicity 2, 5