What is the treatment guide for gout (gouty arthritis) in patients with no current flare?

Treatment Guide for Gout Without Active Flare

For patients with established gout who are not currently experiencing a flare, the primary focus is on initiating and optimizing urate-lowering therapy (ULT) to prevent future flares and complications, with the decision to start ULT depending on disease severity markers. 1

When to Initiate Urate-Lowering Therapy

Strong Indications (Initiate ULT)

Strongly recommend starting ULT for patients with: 1

• Frequent gout flares (≥2 per year) - This represents high disease activity requiring aggressive urate control 1
• Presence of subcutaneous tophi (≥1 tophus) - Indicates advanced disease with tissue urate deposition 1
• Radiographic damage attributable to gout - Any imaging modality showing joint damage from gout 1

Conditional Indications (Consider ULT)

Conditionally recommend initiating ULT for: 1

• Infrequent flares (<2 per year) but with prior history of >1 flare - Lower priority but still beneficial 1
• First gout flare with any of the following high-risk features: 1
  • Chronic kidney disease stage ≥3
  • Serum urate >9 mg/dL
  • History of urolithiasis (kidney stones)

Do NOT Initiate ULT

Conditionally recommend AGAINST starting ULT for: 1

• Asymptomatic hyperuricemia (serum urate >6.8 mg/dL with no prior gout flares or tophi) - The number needed to treat is 24 patients for 3 years to prevent a single incident flare, making routine treatment not worthwhile 1

First-Line Urate-Lowering Therapy

Allopurinol as Preferred Agent

Strongly recommend allopurinol as first-line ULT for all patients, including those with moderate-to-severe chronic kidney disease (stage ≥3). 1

Starting dose: 1

• ≤100 mg/day for most patients
• Lower doses in chronic kidney disease - Adjust based on renal function
• Use low starting doses even though this delays reaching target urate levels, as it reduces the risk of precipitating flares during initiation

Alternative: Febuxostat

Febuxostat is an alternative xanthine oxidase inhibitor if allopurinol is not tolerated or contraindicated. 1

Starting dose: 1

• ≤40 mg/day

Treat-to-Target Strategy

Strongly recommend a treat-to-target approach with serial serum urate monitoring and dose titration. 1

Target Serum Urate Level

• Target: <6 mg/dL 1
• Titrate ULT dose upward gradually based on serial serum urate measurements until target is achieved
• Continue monitoring to ensure sustained urate control

Flare Prophylaxis During ULT Initiation

Strongly recommend concomitant anti-inflammatory prophylaxis when initiating ULT. 1, 2

Duration of Prophylaxis

• Minimum 3-6 months after starting ULT 1
• This prevents the paradoxical increase in flares that occurs when urate levels are being lowered

Prophylaxis Options

First-line prophylaxis agents: 1, 2

• Low-dose colchicine (0.6-1.2 mg/day) 3, 4
• NSAIDs at anti-inflammatory doses
• Low-dose oral corticosteroids if colchicine and NSAIDs are contraindicated

Common pitfall: Starting ULT without prophylaxis dramatically increases the risk of precipitating acute flares during the first several months of therapy 2

Lifestyle Modifications

Conditionally recommend the following lifestyle changes for all gout patients regardless of disease activity: 1

• Limit alcohol intake - especially beer, which is particularly problematic 1
• Limit purine-rich foods - organ meats, shellfish 1, 5
• Limit high-fructose corn syrup intake - found in sweetened beverages 1, 5
• Weight loss program for overweight/obese patients - no specific program endorsed, but weight reduction helps 1
• Encourage low-fat or nonfat dairy products and vegetables 5

Monitoring and Adjustments

If ULT Fails to Achieve Target

For patients on maximum-tolerated xanthine oxidase inhibitor dose with persistent serum urate >6 mg/dL and continued frequent flares (≥2/year) OR nonresolving tophi: 1

• Conditionally recommend switching to a second xanthine oxidase inhibitor (e.g., allopurinol to febuxostat or vice versa) over adding a uricosuric agent 1

Severe Refractory Disease

For patients who have failed xanthine oxidase inhibitors, uricosurics, and other interventions, with continued frequent flares (≥2/year) OR nonresolving tophi: 1

• Strongly recommend switching to pegloticase - requires twice-monthly infusions with risk of allergic reactions, but highly effective for severe disease 1

Strongly recommend AGAINST pegloticase for patients with infrequent flares (<2/year) and no tophi - the costs and harms clearly outweigh minimal benefits in mild disease 1

Key Caveats

• Never treat an acute flare with ULT initiation alone - always provide anti-inflammatory therapy first 2
• Do not stop ULT during an acute flare - continue current ULT if already established 1
• Uricosuric agents should not be used in patients with: 1
  • Known renal calculi
  • Moderate-to-severe CKD (stage ≥3)
• Monitor for drug interactions - particularly with colchicine, which has significant interactions requiring dose adjustments 3