What is the treatment for gout?

Treatment of Gout

For acute gout attacks, start NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 0.5 mg/kg/day) immediately—ideally within 12-24 hours of symptom onset—and for chronic management, initiate urate-lowering therapy with allopurinol or febuxostat targeting serum urate <6 mg/dL in patients with recurrent attacks, tophi, or radiographic changes. 1, 2

Acute Gout Attack Management

First-Line Treatment Options (Choose Based on Contraindications)

NSAIDs:

• Use any NSAID at full anti-inflammatory doses (naproxen, indomethacin, or sulindac) and continue until complete resolution of the attack 1, 2
• Avoid in patients with heart failure, peptic ulcer disease, or significant renal disease 1, 2

Low-Dose Colchicine:

• Dose: 1.2 mg at onset, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 2
• Most effective when started within 12-36 hours of symptom onset 1, 2
• Adjust dose in renal impairment: For severe renal impairment (CrCl <30 mL/min), use single 0.6 mg dose and do not repeat course more than once every two weeks 3
• Avoid with strong CYP3A4 and P-glycoprotein inhibitors (cyclosporine, clarithromycin) due to toxicity risk 2, 3

Oral Corticosteroids:

• Prednisone 0.5 mg/kg/day (or prednisolone 30-35 mg/day) for 5-10 days 1, 2
• Preferred option for patients with renal impairment or contraindications to NSAIDs/colchicine 2, 4

Intra-articular Corticosteroid Injection:

• Highly effective for single joint involvement 1, 2
• Ideal for NPO patients with 1-2 affected joints 2

Treatment Algorithm Based on Severity

Mild-Moderate (1-3 small joints, pain ≤6/10):

• Use monotherapy with any first-line option above 1, 2

Severe (≥4 joints or pain ≥7/10):

• Use combination therapy: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 1, 2

NPO patients with multiple joint involvement:

• Use IV/IM methylprednisolone (0.5-2.0 mg/kg) or subcutaneous ACTH (25-40 IU) 2

Adjunctive Measures

• Apply topical ice to affected joints 1, 2

Managing Inadequate Response

• Define inadequate response as <20% pain improvement within 24 hours or <50% improvement after 24 hours 1, 2
• Switch to alternative monotherapy or add a second agent 2, 4

Long-Term Management of Chronic Gout

Indications for Urate-Lowering Therapy (ULT)

• Recurrent acute attacks (≥2 per year) 1, 2
• Tophi (visible or radiographic) 1, 2
• Chronic gouty arthropathy 1
• Radiographic changes of gout 1, 2
• Do NOT initiate after first gout attack or in patients with infrequent attacks 2

First-Line ULT: Xanthine Oxidase Inhibitors

Allopurinol:

• Start at ≤100 mg/day 2
• Titrate gradually every 2-5 weeks to reach target serum urate <6 mg/dL 1, 2
• Adjust starting dose based on renal function 2

Febuxostat:

• Alternative xanthine oxidase inhibitor, clinically equivalent to allopurinol 2

Alternative ULT: Uricosuric Agents

• Probenecid or benzbromarone for patients with normal renal function and no history of urolithiasis 2
• Losartan (for hypertension) and fenofibrate (for hyperlipidemia) also reduce serum uric acid 2

Target Serum Urate Level

• Maintain serum urate <6 mg/dL 1, 2

Critical ULT Principle

• Do NOT interrupt ongoing ULT during an acute gout attack—continuing therapy improves outcomes 1, 2, 4

Mandatory Prophylaxis During ULT Initiation

Why Prophylaxis is Essential

• Prevents acute flares when starting ULT, which improves medication adherence 1, 2
• Failure to provide prophylaxis leads to breakthrough flares and treatment abandonment 1, 2

Prophylactic Options (Choose One)

• Low-dose colchicine: 0.6 mg once or twice daily (first-line) 1, 2
• Low-dose NSAIDs with gastroprotection if indicated 1, 2
• Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs contraindicated 1, 2

Duration of Prophylaxis

• At least 6 months from ULT initiation 1, 2
• OR 3 months after achieving target serum urate if no tophi present 1, 2
• OR 6 months after achieving target serum urate if tophi present 1, 2

Non-Pharmacologic Measures

• Weight loss for obese patients 1, 2
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 1, 2
• Reduce intake of purine-rich foods (organ meats, shellfish) 2, 5
• Encourage consumption of vegetables and low-fat/nonfat dairy products 2, 5
• Address comorbidities: hyperlipidemia, hypertension, hyperglycemia, obesity, smoking 2

Critical Pitfalls to Avoid

• Never delay treatment beyond 24 hours of symptom onset—effectiveness drops significantly 1, 2, 4
• Never use high-dose colchicine regimens—they cause severe GI toxicity without additional benefit 2, 4
• Never discontinue ULT during acute flares—this worsens outcomes 1, 2, 4
• Never start ULT without concurrent prophylaxis—this guarantees acute flares and poor adherence 1, 2, 4
• Never treat empirically without considering renal function—adjust colchicine and avoid NSAIDs in severe renal impairment 2, 4, 3
• Never ignore drug interactions with colchicine—particularly with CYP3A4/P-glycoprotein inhibitors 2, 3
• Educate patients on "pill in the pocket" approach—self-medicate at first warning symptoms for optimal outcomes 2