Gout Management
Acute Gout Attack Treatment
For acute gout flares, initiate treatment within 24 hours of symptom onset with first-line options including colchicine (1.2 mg loading dose followed by 0.6 mg one hour later), NSAIDs at full anti-inflammatory doses, or oral corticosteroids (30-35 mg/day prednisolone equivalent for 3-5 days). 1, 2, 3
First-Line Treatment Options
Colchicine: Administer 1 mg loading dose followed by 0.5 mg one hour later (total 1.5 mg on day 1), starting within 12 hours of flare onset for optimal efficacy 1, 3
- Low-dose regimens are equally effective as high-dose regimens but with significantly fewer gastrointestinal side effects 1, 2, 4
- Avoid colchicine in patients receiving strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin) due to risk of fatal toxicity 1, 3
- Avoid in severe renal impairment (CrCl <30 mL/min); for dialysis patients, use single 0.6 mg dose, not repeated more than once every two weeks 3
NSAIDs: Use full anti-inflammatory doses with proton pump inhibitor gastroprotection when appropriate 1, 2
Oral corticosteroids: Prednisolone 30-35 mg/day (or equivalent) for 3-5 days 1, 2
Intra-articular corticosteroid injection: Highly effective for single joint involvement (1-2 affected joints) 1, 2, 4
Combination Therapy for Severe Attacks
- For severe pain (≥7/10) or polyarticular involvement, consider combination therapy: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 2
Critical Management Principles
- Continue established urate-lowering therapy without interruption during acute attacks; discontinuation worsens outcomes and perpetuates recurrent flares 2, 4, 5
- Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 1, 2
- Topical ice application as adjunctive measure 2, 4
Long-Term Urate-Lowering Therapy (ULT)
Initiate urate-lowering therapy in patients with recurrent acute attacks (≥2 per year), tophi, chronic gouty arthropathy, or radiographic changes of gout, with a target serum urate level below 6 mg/dL maintained lifelong. 1, 2, 4
Indications for ULT
- Recurrent acute attacks (two or more per year) 2, 4
- Presence of tophi 2, 4
- Chronic gouty arthropathy 2, 4
- Radiographic changes of gout 2, 4
- Chronic kidney disease 5
- Urolithiasis 2
Do NOT initiate ULT after a first gout attack or in patients with infrequent attacks 2
First-Line ULT: Xanthine Oxidase Inhibitors
Allopurinol: Start at ≤100 mg/day and titrate gradually every 2-5 weeks to reach target serum urate <6 mg/dL 2, 4
- Consider HLA-B*5801 testing before initiating in high-risk populations (Koreans with CKD, Han Chinese, Thai) 4
Febuxostat: Alternative xanthine oxidase inhibitor, though associated with increased all-cause and cardiovascular mortality; not routinely recommended as first choice 6
Alternative ULT: Uricosuric Agents
- Probenecid or benzbromarone: Reserved for patients with normal renal function, no history of urolithiasis, and when xanthine oxidase inhibitors cannot be used 2, 4
Target Serum Urate Level
- Maintain serum urate <6 mg/dL (360 μmol/L) lifelong to eliminate urate crystals and prevent flares 1, 2, 4, 5
Mandatory Flare Prophylaxis During ULT Initiation
All patients initiating urate-lowering therapy must receive anti-inflammatory prophylaxis for at least 6 months to prevent mobilization flares. 1, 2, 4, 5, 3
Prophylaxis Options
Low-dose colchicine: 0.5-1 mg daily (first-line) 1, 2, 4, 5, 3
Low-dose NSAIDs with gastroprotection: Appropriate alternative when colchicine contraindicated 2, 4, 5
Low-dose prednisone: When both colchicine and NSAIDs are contraindicated 2, 4, 5
Duration of Prophylaxis
- Continue for at least 6 months after starting ULT 1, 2, 4
- OR 3 months after achieving target serum urate if no tophi present 2, 4
- OR 6 months after achieving target serum urate if tophi have resolved 2, 4
Critical Pitfall
- Failure to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence, undermining treatment success 2, 4, 5
Lifestyle and Non-Pharmacologic Management
Every patient with gout must receive comprehensive lifestyle counseling as an integral part of management. 1, 2
Dietary Modifications
- Weight loss if obese 1, 2, 4, 5
- Avoid alcohol, especially beer and spirits 1, 2, 4
- Eliminate sugar-sweetened drinks and beverages with high-fructose corn syrup 1, 2, 5
- Reduce intake of purine-rich foods: organ meats, red meat, and seafood 1, 2, 5
- Encourage consumption of low-fat or nonfat dairy products and vegetables 1, 2, 5
- Regular exercise 1, 5
Management of Associated Comorbidities
Systematically screen for and address cardiovascular risk factors and comorbidities including renal impairment, coronary heart disease, heart failure, stroke, obesity, hyperlipidemia, hypertension, diabetes, and smoking. 1, 2
Medication Optimization
- Discontinue or substitute diuretics (thiazides, loop diuretics) when possible, as they are the most common iatrogenic cause of gout 5
- Switch to losartan for hypertension management (has modest uricosuric effects) 5
- Consider fenofibrate for hyperlipidemia (has uricosuric properties) 5
- Optimize diabetes control as hyperglycemia worsens hyperuricemia 5
Patient Education: The Foundation of Successful Management
Every patient with gout must be fully informed about disease pathophysiology, the existence of effective treatments, associated comorbidities, and the principles of managing acute attacks and eliminating urate crystals through lifelong serum urate lowering. 1