What are the treatment options for gout?

Gout Treatment

For acute gout attacks, initiate treatment within 24 hours with 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 consult their provider for each attack 1

First-Line Monotherapy Options (Mild-Moderate Attacks)

For attacks with pain ≤6/10 on a 0-10 scale 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), though other NSAIDs at full anti-inflammatory doses are equally effective 1
• Add proton pump inhibitor therapy where indicated for gastroprotection 1
• Avoid NSAIDs in patients with chronic kidney disease (CrCl <30 mL/min), congestive heart failure, active peptic ulcer disease, or cirrhosis 1

Oral Corticosteroids

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

Low-Dose Colchicine

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

Combination Therapy (Severe/Polyarticular Attacks)

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

• Acceptable combinations include: 1
  • Colchicine + NSAIDs
  • Oral corticosteroids + colchicine
  • Intra-articular steroids with any other modality

Special Populations

NPO (Nil Per Os) Patients

• Intra-articular corticosteroid injection for 1-2 accessible joints (dose varies by joint size) 1
• Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg as alternative 1
• Subcutaneous ACTH 25-40 IU with repeat doses as clinically indicated 1

Patients with Severe Renal Impairment

• Corticosteroids are the safest option; avoid NSAIDs and use colchicine with extreme caution and dose adjustment 1, 5

Inadequate Response to Initial Therapy

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

Adjunctive Non-Pharmacologic Therapy

• Topical ice application is appropriate as adjunctive measure to pharmacologic therapy 1, 3, 5

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate ULT in patients with: 2, 3, 5

• Recurrent acute gout attacks (≥2 per year)
• Tophaceous gout (tophi on physical exam)
• Chronic gouty arthropathy
• Radiographic changes of gout
• History of urolithiasis

Target and First-Line Agent

• Target serum urate level <6 mg/dL (357 μmol/L) 1, 2, 3
• Allopurinol is the preferred first-line agent, including for patients with moderate-to-severe chronic kidney disease 1, 2, 5
• Start allopurinol at ≤100 mg/day (50 mg/day in stage 4 or worse CKD) and titrate gradually every 2-5 weeks to reach target 2, 5

Alternative ULT Agents

• Febuxostat is an alternative xanthine oxidase inhibitor 1, 2
• Uricosuric agents (probenecid, benzbromarone) for patients with normal renal function, no history of urolithiasis, and allopurinol intolerance 1, 5

Anti-Inflammatory Prophylaxis During ULT Initiation

Indications and Timing

• Mandatory anti-inflammatory prophylaxis for all patients when initiating ULT to prevent flares 1, 2
• 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
• Adjust for renal impairment: 1, 4
  • Mild-moderate impairment (CrCl 30-80 mL/min): Monitor closely, dose adjustment may not be required
  • Severe impairment (CrCl <30 mL/min): Start 0.3 mg/day
  • Dialysis patients: 0.3 mg twice weekly
• Adjust for hepatic impairment: Dose reduction in severe hepatic impairment 4

Low-Dose NSAIDs (Alternative First-Line)

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

Low-Dose Prednisone/Prednisolone (Second-Line)

• <10 mg/day for patients with contraindications to both colchicine and NSAIDs 1, 2, 3
• Doses above 10 mg/day are inappropriate for prophylaxis in most scenarios 1

Duration of Prophylaxis

Continue prophylaxis for the greater of: 1, 2

• 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 tophi previously detected)

Lifestyle Modifications

• Weight loss for obese patients 1, 2, 5, 6
• Avoid alcoholic drinks (especially beer and spirits) and beverages sweetened with high-fructose corn syrup 1, 2, 5, 6
• Reduce intake of purine-rich foods (organ meats, shellfish) 1, 5, 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products 1, 5, 6
• Discontinue diuretics if possible, as they increase uric acid levels 1, 6

Critical Pitfalls to Avoid

• Never delay treatment beyond 24 hours—early initiation is the most important determinant of therapeutic success 1, 3
• Never discontinue ULT during acute attacks—this worsens outcomes and prolongs disease activity 1, 3
• Never start ULT without concurrent anti-inflammatory prophylaxis—this leads to acute flares and poor medication adherence 1, 2, 3
• Never use high-dose colchicine regimens—low-dose regimens are equally effective with significantly fewer gastrointestinal side effects 1, 3, 5
• Always screen for and adjust colchicine dose in renal/hepatic impairment and drug interactions—failure to do so risks serious toxicity 1, 5, 4
• Never use NSAIDs in patients with significant renal disease (CrCl <30 mL/min), heart failure, or active peptic ulcer disease 1, 5