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, 2
• Continue established urate-lowering therapy (ULT) without interruption during acute attacks—do not stop ULT during a flare 1, 2
• Educate patients to self-initiate treatment at first warning symptoms without needing to consult their provider for each attack 1

First-Line Monotherapy Options (Mild-Moderate Attacks)

For attacks with pain ≤6/10 involving 1-3 small joints or 1-2 large joints, choose one of the following 1:

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—any NSAID at full anti-inflammatory doses is effective 1
• Avoid NSAIDs in patients with chronic kidney disease (CKD), congestive heart failure, peptic ulcer disease, cirrhosis, or on anticoagulation 1, 3, 2
• For patients with GI contraindications, consider celecoxib: 800 mg once, then 400 mg on day 1, then 400 mg twice daily for one week (Evidence C, unclear risk-benefit ratio) 1

Oral Colchicine

• Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 1, 3, 2
• Dosing: 1.2 mg at onset, followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours) 1, 2, 4
• After initial dosing, can continue low-dose colchicine (0.6 mg twice daily) starting at least 12 hours later until attack resolves 1
• Adjust dose for renal impairment: In severe renal failure (CrCl <30 mL/min), reduce to single 0.6 mg dose; for dialysis patients, use single 0.6 mg dose and do not repeat course 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
• Do not use colchicine for acute attacks in patients already on colchicine prophylaxis—choose alternative therapy 1, 4

Oral Corticosteroids

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

Combination Therapy (Severe/Polyarticular Attacks)

For severe pain (≥7/10) or polyarticular involvement (≥4 joints), use combination therapy 1, 2:

• Acceptable combinations include: 1
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality
• Do not combine NSAIDs with systemic corticosteroids due to synergistic GI toxicity 1

Special Populations

NPO (Nil Per Os) Patients

• For 1-2 affected joints: Intra-articular corticosteroid injection (dose depends on joint size) 1, 3, 2
• For multiple joints: Intravenous or intramuscular methylprednisolone 0.5-2.0 mg/kg, or subcutaneous ACTH 25-40 IU with repeat doses as needed 1, 5

Renal Impairment

• Corticosteroids are the safest option in moderate-to-severe renal impairment 5
• Avoid NSAIDs in significant renal disease 1, 3, 2
• Adjust colchicine dose as described above 4

Inadequate Response to Initial Therapy

• Define inadequate response as: <20% improvement in pain within 24 hours OR <50% improvement after 24 hours 1, 2, 5
• Switch to another monotherapy or add a second appropriate agent 1

Adjunctive Non-Pharmacologic Measures

• Apply topical ice to inflamed joints as an adjunctive measure to pharmacologic therapy 1, 2, 5
• Rest the affected joint 6

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate ULT in patients with: 1, 3, 2, 5

• Recurrent acute gout attacks
• Tophaceous gout (tophi on physical exam)
• Chronic gouty arthropathy
• Radiographic changes of gout
• History of nephrolithiasis

ULT Agents and Dosing

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options 1, 3, 2, 5
• Allopurinol starting dose: ≤100 mg/day (50 mg/day in stage 4 or worse CKD), titrate gradually every 2-5 weeks to reach target 3, 5
• Target serum urate level: <6 mg/dL (357 μmol/L) 1, 3, 2, 5
• Titrate allopurinol to achieve target serum urate rather than using a standard dose 5
• Uricosuric agents (probenecid, benzbromarone) are alternatives in patients with normal renal function, no history of urolithiasis, and allopurinol intolerance 1, 5, 6, 7

Anti-Inflammatory Prophylaxis During ULT Initiation

Indications and Timing

• Mandatory anti-inflammatory prophylaxis is required when starting ULT to prevent flares 1, 3, 2, 5
• Initiate prophylaxis with or just before starting ULT 1, 3, 2

First-Line Prophylaxis Options

Low-Dose Colchicine (First-Line)

• Dosing: 0.5-0.6 mg once or twice daily 1, 3, 2
• Adjust for renal impairment: 1, 4
  • Mild-moderate impairment (CrCl 30-80 mL/min): Monitor closely, may not require dose adjustment
  • Severe impairment (CrCl <30 mL/min): Start with 0.3 mg/day
  • Dialysis patients: 0.3 mg twice weekly
• Adjust for drug interactions with CYP3A4 and P-glycoprotein inhibitors 1, 5, 4

Low-Dose NSAIDs (Alternative First-Line)

• Example: Naproxen 250 mg twice daily 1, 3, 2
• Add proton pump inhibitor where indicated for gastroprotection 1, 3, 2
• Contraindicated in patients with renal disease, heart failure, or peptic ulcer disease 1, 3, 2

Low-Dose Prednisone (Second-Line)

• Dosing: <10 mg/day 1, 3, 2
• Use only if colchicine and NSAIDs are both contraindicated, not tolerated, or ineffective 1, 3, 2
• Do not use doses >10 mg/day for prophylaxis—inappropriate in most scenarios 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 3, 2, 5

• 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 and resolution of tophi (for patients with history of tophi)

Continue prophylaxis if there is any clinical evidence of continuing gout disease activity (recent acute attacks, chronic gouty arthritis, or tophi present) 1

Lifestyle Modifications

• Weight loss for obese patients 1, 3, 5, 8
• Avoid alcohol (especially beer and spirits) and sugar-sweetened beverages with high-fructose corn syrup 1, 3, 5, 8
• Reduce intake of purine-rich foods (organ meats, shellfish) 1, 5, 8
• Encourage consumption of vegetables and low-fat or nonfat dairy products 5, 8
• Discontinue diuretics if possible, as they increase uric acid levels 1, 8
• Consider losartan for hypertension and fenofibrate for hyperlipidemia, as both reduce serum uric acid 5, 8, 7

Critical Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2, 5
• Never discontinue ULT during acute flares—this worsens outcomes 1, 2, 5
• Failure to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 1, 3, 2, 5
• High-dose colchicine regimens cause significant GI toxicity with no additional benefit—use low-dose regimens only 1, 5
• Inadequate duration of prophylaxis leads to breakthrough flares—continue for at least 6 months 1, 3, 2, 5
• Using standard allopurinol doses without titration to target serum urate leads to treatment failure 5, 7
• Colchicine drug interactions can cause serious toxicity—always check for CYP3A4 and P-glycoprotein inhibitors 1, 5, 4