What is the recommended management for gout symptoms?

Management of Gout Symptoms

For acute gout attacks, initiate treatment immediately—within 12-24 hours of symptom onset—with first-line options including low-dose colchicine (1 mg loading dose followed by 0.5 mg one hour later), NSAIDs at full anti-inflammatory doses, or oral corticosteroids (30-35 mg prednisolone equivalent daily for 3-5 days), selecting based on contraindications and comorbidities. 1, 2, 3

Acute Gout Attack Management

Immediate Treatment Approach

• Start treatment as early as possible—effectiveness decreases significantly if delayed beyond 24 hours of symptom onset 1, 2, 3

• Educate patients on the "pill in the pocket" approach so they can self-medicate at the first warning symptoms 1, 2, 3

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

First-Line Pharmacologic Options

Low-dose colchicine:

• Most effective when started within 12 hours of symptom onset 1, 2, 3
• Dosing: 1 mg loading dose followed by 0.5 mg one hour later on day 1, maximum 2 mg/day 1, 3
• Avoid high-dose regimens—they cause significant gastrointestinal toxicity with no additional benefit 1, 2, 3
• Must avoid in patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporin, clarithromycin) due to serious toxicity risk 1, 2
• Avoid in severe renal impairment 1, 2

NSAIDs at full anti-inflammatory doses:

• No single NSAID is superior to another—use any at full anti-inflammatory doses 2, 4
• Add proton pump inhibitor if gastrointestinal risk factors present 1, 3
• Continue at full dose until acute attack completely resolves 2
• Avoid in patients with heart failure, peptic ulcer disease, or significant renal disease 2

Oral corticosteroids:

• Prednisolone 30-35 mg/day (or equivalent) for 3-5 days 1, 2, 3
• Preferred option for patients with severe renal impairment or contraindications to NSAIDs and colchicine 1, 2
• Safest option in patients with chronic kidney disease 2

Intra-articular corticosteroid injection:

• Highly effective for single joint involvement 1, 2, 3
• Recommended for NPO patients with 1-2 affected joints 2

Combination Therapy for Severe Presentations

• For severe pain (≥7/10) or polyarticular involvement, consider combination therapy: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 2

Adjunctive Measures

• Topical ice application is recommended as an adjunctive measure during acute attacks 2, 4

Long-Term Management and Urate-Lowering Therapy

Indications for Urate-Lowering Therapy

• Do NOT initiate urate-lowering therapy after a first gout attack or in patients with infrequent attacks 2, 3

• Initiate urate-lowering therapy in patients with:

  • Recurrent acute attacks 1, 2, 3
  • Tophi (visible or radiographic) 1, 2, 3
  • Radiographic changes of gout 1, 2, 3
  • Chronic gouty arthropathy 3
  • Young age (<40 years) with very high uric acid (>8 mg/dL) 3

Urate-Lowering Therapy Protocol

Allopurinol (first-line agent):

• Start at 100 mg daily 2, 3, 5
• Titrate upward by 100 mg every 2-5 weeks 2, 3, 5
• Target serum urate level: <6 mg/dL (360 μmol/L) 2, 3, 5
• Maximum recommended dose: 800 mg daily 5
• Can be used in moderate-to-severe chronic kidney disease with dose adjustment 2
• With creatinine clearance 10-20 mL/min: 200 mg daily 5
• With creatinine clearance <10 mL/min: maximum 100 mg daily 5

Alternative agents:

• Febuxostat: alternative xanthine oxidase inhibitor 2, 6
• Uricosuric agents (probenecid, benzbromarone): for patients with normal renal function and no history of urolithiasis 1, 2, 4

Mandatory Prophylaxis During Urate-Lowering Therapy Initiation

• Anti-inflammatory prophylaxis is strongly recommended when starting urate-lowering therapy to prevent flares 2, 3

• Prophylactic options:

  • Low-dose colchicine 0.5-1 mg daily (preferred) 1, 2, 3
  • Low-dose NSAIDs with gastroprotection 1, 2
  • Low-dose prednisone 2, 3

• Duration of prophylaxis:

  • Minimum 6 months 2, 3
  • OR 3 months after achieving target serum urate if no tophi present 2, 3
  • OR 6 months after achieving target serum urate if tophi present 2
  • Continue longer if attacks persist, even beyond 6 months 3

Non-Pharmacologic Management

Lifestyle Modifications

• Weight loss if obese 1, 2, 3, 6
• Avoid alcoholic drinks, especially beer and spirits 1, 2, 3, 6
• Eliminate beverages sweetened with high-fructose corn syrup 2, 3, 6
• Reduce intake of purine-rich foods (organ meats, shellfish) 2, 6
• Encourage consumption of vegetables and low-fat or nonfat dairy products 2, 3, 6
• Regular exercise 2, 3

Comorbidity Management

• Screen and address associated comorbidities: hyperlipidemia, hypertension, hyperglycemia, obesity, smoking 1, 2, 3
• Consider losartan for hypertension—it reduces serum uric acid levels 2, 6
• Consider fenofibrate for hyperlipidemia—it reduces serum uric acid levels 2
• Discontinue diuretics if possible when gout is associated with their use 1, 6
• Calculate estimated glomerular filtration rate (eGFR) at diagnosis and monitor regularly 1

Common Pitfalls and Caveats

• Delaying treatment beyond 24 hours significantly reduces effectiveness 2
• Discontinuing urate-lowering therapy during acute flares is a major error—continue without interruption 2, 3
• Inadequate duration of prophylaxis when initiating urate-lowering therapy leads to breakthrough flares and poor medication adherence 2
• Starting allopurinol at high doses increases risk of hypersensitivity reactions—always start low and titrate slowly 2, 3, 5
• Using standard allopurinol doses without titration to target—must titrate to achieve serum urate <6 mg/dL, not just use 300 mg daily 2
• Colchicine drug interactions are potentially fatal—always check for CYP3A4 and P-glycoprotein inhibitors before prescribing 1, 2