What are the treatment options for gout?

Gout Treatment

For acute gout attacks, initiate treatment within 24 hours using NSAIDs, oral corticosteroids, or low-dose colchicine as first-line monotherapy options, selecting based on comorbidities and contraindications. 1

Acute Gout Attack Management

Treatment Initiation and General Principles

• Start pharmacologic therapy within 24 hours of symptom onset for optimal outcomes, as delayed treatment significantly reduces effectiveness 1
• Continue established urate-lowering therapy (ULT) without interruption during acute attacks—do not stop ULT during a flare 1
• Educate patients to self-initiate treatment at first warning symptoms without needing to contact their provider for each attack 1

First-Line Monotherapy Options (for mild-moderate attacks involving 1-3 small joints or 1-2 large joints)

NSAIDs:

• Use full FDA/EMA-approved anti-inflammatory doses and continue until the attack completely resolves 1
• FDA-approved options include naproxen (Evidence A), indomethacin (Evidence A), and sulindac (Evidence B) 1
• No single NSAID is superior—select based on patient factors 1
• Avoid in patients with chronic kidney disease, congestive heart failure, peptic ulcer disease, cirrhosis, or on anticoagulation 1, 2, 3

Oral Colchicine:

• Dosing: 1.2 mg at onset, followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours) 1, 2, 3
• Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 1, 2
• For patients already on prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid) 1
• Adjust dose for renal impairment: In severe renal impairment (CrCl <30 mL/min) or dialysis patients, use single dose of 0.6 mg and do not repeat more than once every two weeks 4
• Adjust for drug interactions: Reduce dose or avoid with strong CYP3A4 and P-glycoprotein inhibitors (e.g., clarithromycin, cyclosporine) 1, 5, 4

Oral Corticosteroids:

• Prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, OR taper over 7-10 days 1, 2, 3
• Alternative: Prednisone 30-35 mg/day for 3-5 days 2
• Particularly useful for patients with contraindications to NSAIDs or colchicine 1, 2
• Avoid in patients with diabetes, active infection, or high infection risk 2

Combination Therapy (for severe pain ≥7/10 or polyarticular attacks involving ≥4 joints)

• Appropriate combinations include: 1
  • Colchicine + NSAIDs (full doses)
  • Oral corticosteroids + colchicine
  • Intra-articular steroids + any other modality
• Do not combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Special Populations

NPO (Nil Per Os) Patients:

• Intra-articular corticosteroid injection for 1-2 accessible joints (dose depends on joint size) 1, 2
• Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg as alternative 1
• Subcutaneous ACTH 25-40 IU as alternative 1

Renal Impairment:

• Corticosteroids are the safest option in severe renal impairment 5
• Avoid NSAIDs and adjust colchicine dosing as above 1, 5, 4

Adjunctive Measures

• Topical ice application to affected joint is appropriate adjunctive therapy 1, 2, 3
• Rest the inflamed joint 6

Inadequate Response Definition and Management

• Inadequate response = <20% improvement in pain within 24 hours OR <50% improvement after 24 hours 1, 3
• For inadequate response: Switch to another monotherapy or add a second appropriate agent 1

---

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

• Initiate ULT in patients with: 2, 3, 5
  • Recurrent acute attacks (≥2 per year)
  • Tophaceous gout
  • Chronic gouty arthropathy
  • Radiographic changes of gout
  • History of nephrolithiasis

Target and First-Line Agents

• Target serum urate level: <6 mg/dL (357 μmol/L) 1, 2, 3, 5
• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options 1, 2, 5
• Allopurinol starting dose: ≤100 mg/day (50 mg/day in stage 4 or worse CKD), then titrate every 2-5 weeks to reach target 2, 5

---

Anti-Inflammatory Prophylaxis During ULT Initiation

Rationale and Timing

• Mandatory prophylaxis when starting ULT to prevent acute flares 1, 2, 3
• Initiate prophylaxis with or just prior to starting ULT 1, 2

First-Line Prophylaxis Options

Low-dose Colchicine (First-line):

• Dosing: 0.6 mg once or twice daily (0.5 mg once or twice daily outside US) 1, 2, 3
• Adjust for renal impairment and drug interactions 1, 4

Low-dose NSAIDs (Second-line):

• Example: Naproxen 250 mg twice daily 1, 2
• Use with proton pump inhibitor where indicated 1, 2

Low-dose Prednisone/Prednisolone:

• <10 mg/day if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1, 2, 3
• Monitor carefully for corticosteroid-related adverse effects, especially in patients with diabetes or infection risk 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 2, 3

• At least 6 months duration, OR
• 3 months after achieving target serum urate (for patients without tophi on physical exam), OR
• 6 months after achieving target serum urate (for patients with tophi detected on physical exam, continued until tophi resolution)

---

Lifestyle Modifications

• Weight loss for obese patients 1, 2, 5, 7
• Avoid alcohol (especially beer and spirits) 1, 2, 5, 7
• Avoid sugar-sweetened beverages and high-fructose corn syrup 2, 5, 7
• Reduce intake of purine-rich foods (organ meats, shellfish) 1, 5, 7
• Encourage consumption of vegetables and low-fat or nonfat dairy products 5, 7
• Discontinue diuretics if possible when gout is associated with diuretic use 1

---

Common Pitfalls and How to Avoid Them

• Delaying treatment beyond 24 hours significantly reduces effectiveness—educate patients on early self-treatment 1, 3, 5
• Stopping ULT during acute attacks worsens outcomes—always continue ULT without interruption 1, 3
• Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence—mandatory prophylaxis for at least 6 months 1, 3
• Using high-dose colchicine regimens causes significant GI toxicity with no additional benefit—use low-dose regimen only 1, 5
• Inadequate duration of prophylaxis leads to breakthrough flares—continue for specified duration based on tophi presence and urate target achievement 1, 3
• Ignoring drug interactions with colchicine can cause serious toxicity—adjust dose with CYP3A4/P-glycoprotein inhibitors and in renal impairment 1, 5, 4