What are the treatment options for managing gout?

Management of Gout

For acute gout attacks, initiate treatment within 12-24 hours with first-line options including low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs at full anti-inflammatory doses, or oral corticosteroids (30-35 mg prednisolone equivalent for 3-5 days), and for chronic management, start urate-lowering therapy with allopurinol in patients with recurrent attacks (≥2/year), tophi, or radiographic damage, targeting serum urate <6 mg/dL. 1, 2, 3

Acute Gout Attack Management

Timing and Initial Treatment Selection

• Treatment must begin within 12-24 hours of symptom onset for optimal effectiveness—delays beyond this window significantly reduce treatment efficacy. 2, 3

• First-line monotherapy options (choose based on contraindications and patient factors): 1, 2

  • Low-dose colchicine: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over one hour)—most effective when started within 12 hours of onset 1, 4
  • NSAIDs at full anti-inflammatory doses with proton pump inhibitor if GI risk factors present 1, 2
  • Oral corticosteroids: prednisolone 30-35 mg/day for 3-5 days 1, 2
  • Intra-articular corticosteroid injection for single joint involvement 1, 2

Escalation for Severe or Polyarticular Disease

• For severe pain (≥7/10) or multiple joint involvement, use combination therapy: 2
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality

Special Population Considerations

• Renal impairment (CrCl <30 mL/min): Corticosteroids are safest option; avoid NSAIDs and colchicine 1, 4

  • If colchicine used in severe renal impairment: single 0.6 mg dose for acute treatment, repeat no more than once every 2 weeks 4
  • For dialysis patients: 0.6 mg single dose, repeat no more than once every 2 weeks 4

• Severe hepatic impairment: Corticosteroids preferred; if colchicine used, treatment course repeated no more than once every 2 weeks 4

• NPO patients: 2

  • 1-2 joints: intra-articular corticosteroid injection
  • Multiple joints: IV/IM methylprednisolone 0.5-2.0 mg/kg or subcutaneous ACTH 25-40 IU

Critical Drug Interactions with Colchicine

• Absolute contraindication: Do not give colchicine with strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, ritonavir, ketoconazole, itraconazole)—fatal toxicity reported 1, 4

• If strong CYP3A4 inhibitor unavoidable: Reduce colchicine dose to 0.6 mg × 1 dose followed by 0.3 mg one hour later; repeat no earlier than 3 days 4

Adjunctive Measures

• Topical ice application to affected joint 2, 3

• Continue established urate-lowering therapy without interruption during acute attacks 2

• Educate patients on "pill in the pocket" approach—self-medicate at first warning symptoms 1, 2

Long-Term Urate-Lowering Therapy (ULT)

Indications for Starting ULT

• Initiate ULT in patients with: 1, 2, 3

  • Recurrent acute attacks (≥2 per year)
  • Tophaceous gout
  • Radiographic changes of gout
  • Chronic kidney disease
  • History of urolithiasis

• Do NOT initiate ULT after first gout attack or in patients with infrequent attacks 2

First-Line ULT: Allopurinol

• Allopurinol is the preferred first-line agent, including for patients with moderate-to-severe chronic kidney disease (stage ≥3) 1, 2, 3

• Starting dose: ≤100 mg/day 2, 3

  • CrCl 50-80 mL/min: start 100 mg/day
  • CrCl 30-50 mL/min: start 50-100 mg/day
  • CrCl <30 mL/min: start 50 mg/day or less

• Titration: Increase by 50-100 mg every 2-5 weeks until target serum urate achieved 2

• Target serum urate: <6 mg/dL (360 μmol/L) for all patients; <5 mg/dL (300 μmol/L) for severe gout with tophi 1, 2, 3

Second-Line ULT Options

• If target not achieved with allopurinol or allopurinol not tolerated: 1

  • Febuxostat (xanthine oxidase inhibitor)
  • Uricosuric agents (probenecid, benzbromarone) in patients with normal renal function and no urolithiasis history
  • Combination of xanthine oxidase inhibitor plus uricosuric

• For refractory gout: Pegloticase 1

Mandatory Prophylaxis When Starting ULT

• Anti-inflammatory prophylaxis is mandatory when initiating ULT to prevent mobilization flares 2, 3

• Prophylaxis options: 1, 2, 3

  • Low-dose colchicine 0.5-1 mg/day (preferred)
  • Low-dose NSAIDs with gastroprotection
  • Low-dose prednisone

• Duration of prophylaxis: 2, 3

  • Minimum 6 months, OR
  • 3 months after achieving target serum urate if no tophi present, OR
  • 6 months after achieving target serum urate if tophi present

• Colchicine dose adjustment for prophylaxis in renal impairment: 3

  • CrCl 30-50 mL/min: 0.5 mg daily or every other day
  • CrCl <30 mL/min: 0.3 mg/day starting dose
  • Dialysis: 0.3 mg twice weekly

Lifestyle Modifications and Comorbidity Management

Dietary and Lifestyle Counseling

• Weight loss if obese 1, 2, 3

• Avoid: 1, 2, 3

  • Alcohol, especially beer and spirits
  • Sugar-sweetened beverages and high-fructose corn syrup
  • Excessive intake of purine-rich foods (organ meats, shellfish, red meat)

• Encourage: 1, 2

  • Low-fat or nonfat dairy products
  • Vegetables
  • Regular exercise

Systematic Comorbidity Screening

• Screen all gout patients for cardiovascular risk factors and comorbidities: renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidemia, hypertension, diabetes, smoking 1, 3

• Medication optimization for comorbidities: 3

  • Hypertension: Consider switching to losartan (modest uricosuric effect) or calcium channel blockers; discontinue thiazide/loop diuretics if possible
  • Hyperlipidemia: Consider fenofibrate (has uricosuric properties)

Common Pitfalls and How to Avoid Them

• Delaying treatment beyond 24 hours reduces effectiveness—educate patients on early self-treatment 2, 3

• Using high-dose colchicine regimens causes significant GI toxicity with no additional benefit—always use low-dose regimen 1, 2

• Discontinuing ULT during acute flares—continue ULT without interruption 2, 3

• Inadequate prophylaxis duration when starting ULT—leads to breakthrough flares and poor adherence; maintain for minimum 6 months 2, 3

• Insufficient allopurinol dosing—must titrate to achieve target serum urate <6 mg/dL, not just use standard 300 mg dose 2, 3

• Using NSAIDs in patients with heart failure, peptic ulcer disease, or significant renal disease—use corticosteroids instead 2

• Ignoring colchicine drug interactions—fatal toxicity reported with strong CYP3A4/P-gp inhibitors 1, 4