From the Guidelines
The treatment protocol for gout should prioritize acute management with colchicine, NSAIDs, or corticosteroids, and long-term prevention with urate-lowering therapy, such as allopurinol or febuxostat, to achieve a serum uric acid level below 6mg/dL, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
Acute Management
For acute gout attacks, the following options are recommended:
- Colchicine, given as 1mg initially, followed by 0.5mg one hour later, then 0.5mg once or twice daily until the attack subsides, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1
- NSAIDs, such as naproxen or indomethacin, typically continued for 7-10 days until symptoms resolve
- Corticosteroids, such as prednisone, for patients who cannot take NSAIDs or colchicine
Long-term Prevention
For long-term management in patients with recurrent attacks, urate-lowering therapy is recommended, with the following options:
- Allopurinol, starting at 100mg daily and gradually increasing to achieve a serum uric acid level below 6mg/dL, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1
- Febuxostat, an alternative for those who cannot tolerate allopurinol
Lifestyle Modifications
Lifestyle modifications are also important, including:
- Weight loss if overweight
- Limiting alcohol (especially beer)
- Avoiding high-purine foods like organ meats and shellfish
- Staying well-hydrated
- Regular exercise and a healthy diet, as recommended by the American College of Physicians 1 These treatments work by either reducing inflammation during acute attacks or lowering uric acid levels to prevent crystal formation in joints, which is the underlying cause of gout pain and inflammation.
From the FDA Drug Label
The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The average is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout The recommended dose and regimen of KRYSTEXXA for adult patients is 8 mg (uricase protein) given as an intravenous infusion every two weeks. Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis.
The treatment protocol for gout involves:
- Allopurinol (PO): The dosage varies with the severity of the disease, with an average of 200 to 300 mg/day for mild gout and 400 to 600 mg/day for moderately severe tophaceous gout 2
- Pegloticase (IV): The recommended dose is 8 mg given as an intravenous infusion every two weeks for adult patients with chronic gout refractory to conventional therapy 3
- Probenecid (PO): Indicated for the treatment of hyperuricemia associated with gout and gouty arthritis 4 Key considerations:
- The dosage of allopurinol should be adjusted based on serum uric acid levels and the severity of the disease
- Pegloticase should be administered in a healthcare setting with monitoring for anaphylaxis and infusion reactions
- Probenecid can be used as an adjuvant to therapy with certain antibiotics.
From the Research
Treatment Protocol for Gout
The treatment protocol for gout involves both the management of acute flares and long-term urate-lowering therapy.
- Acute flares can be managed with standard pharmacotherapies such as colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 5.
- Urate-lowering therapies aim to prevent gout flares, with an emphasis on a treat-to-target strategy, where therapies are escalated until the target serum uric acid is reached 5, 6.
Urate-Lowering Therapies
Urate-lowering therapies include:
- Allopurinol and febuxostat as initial treatments 5, 6, 7, 8.
- Uricosuric agents such as probenecid, sulfinpyrazone, and benzbromarone as adjuncts 5, 6, 7, 8.
- Pegloticase, a uricase, for patients with severe gout who are refractory to other treatments 7, 8.
Emerging Therapies
There are also emerging therapies in development for the treatment of gout, including new urate-lowering therapies and anti-inflammatory agents 5, 6.
Personalization of Treatment
Treatment is increasingly being personalized, with pharmacotherapy adjusted based on comorbidities such as chronic kidney disease and ischemic heart disease, as well as patient preference 5.