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:

• Chronic kidney disease
• History of urolithiasis
• After first gout attack in younger patients

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 10-20 mL/min: 200 mg/day maximum 5
  • CrCl <10 mL/min: 100 mg/day maximum 5
  • Dialysis patients: 100 mg/day maximum with extended dosing intervals 5

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

  • Maximum dose: 800 mg/day 5

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

  • Lower target <5 mg/dL (300 μmol/L) 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 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 1

  • Benzbromarone more effective than allopurinol but may be hepatotoxic 1

• Combination therapy: Allopurinol plus uricosuric if monotherapy inadequate 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 prophylaxis 1, 3
• Alternative: Low-dose NSAID with gastroprotection if indicated 1
• Continue until serum uric acid normalized and patient flare-free for several months 5

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 every 2-4 weeks during titration, then periodically 1

Lifestyle Modifications

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

• Weight loss if overweight/obese (no specific program endorsed) 1
• Limit alcohol intake, especially beer and spirits 1
  • Wine consumption does not increase serum uric acid 1
• Limit purine intake (organ meats, shellfish) 1
• Limit high-fructose corn syrup and sugar-sweetened beverages 1
• Encourage low-fat dairy products 1
• Regular exercise 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 1

Common Pitfalls to Avoid

• Do not treat asymptomatic hyperuricemia pharmacologically 7
• Do not start ULT during acute flare unless already established on therapy 3
• Do not use high-dose colchicine (>1.8 mg in first hour) due to toxicity without added benefit 1, 3
• Do not initiate ULT without concurrent flare prophylaxis 1
• Do not underdose allopurinol - titrate to serum uric acid target, not to arbitrary dose 1
• Adjust colchicine dose in renal/hepatic impairment and with CYP3A4 inhibitors 2