What are the treatment options for gout?

Gout Medication Treatment Options

Acute Gout Attack Management

For acute gout attacks, initiate treatment within 24 hours with first-line options: NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (30-35 mg prednisolone equivalent daily for 3-5 days). 1

First-Line Monotherapy Options

• NSAIDs at full anti-inflammatory doses (e.g., naproxen 500 mg twice daily) are preferred for attacks involving 1-3 small joints or 1-2 large joints when started promptly 1, 2
• Low-dose colchicine is most effective when started within 12 hours of symptom onset, using 1.2 mg followed by 0.6 mg one hour later 1, 3
• Oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days) are particularly useful for patients with contraindications to NSAIDs or colchicine 1, 3
• Intra-articular corticosteroid injection is highly effective for single joint involvement 1, 2

Combination Therapy for Severe Attacks

• For severe pain (≥7/10) or polyarticular involvement, use combination therapy: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 1

Special Population Considerations

• Renal impairment patients: Corticosteroids are the safest option; avoid NSAIDs and use colchicine cautiously 1, 4
• Severe renal impairment (CrCl <30 mL/min): For colchicine, use single 0.6 mg dose and do not repeat more than once every two weeks 4
• Dialysis patients: Use single 0.6 mg colchicine dose, not repeated more than once every two weeks 4
• NPO patients with 1-2 joints: Use intra-articular corticosteroid injection 1
• NPO patients with multiple joints: Use IV/IM methylprednisolone (0.5-2.0 mg/kg) or subcutaneous ACTH (25-40 IU) 1

Critical Management Principles

• Continue established urate-lowering therapy without interruption during acute attacks 1, 2
• Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 1
• Topical ice application is recommended as adjunctive therapy 1, 2

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Long-Term Urate-Lowering Therapy (ULT)

Initiate urate-lowering therapy in patients with recurrent acute attacks (≥2 per year), tophi, chronic gouty arthropathy, or radiographic changes of gout, targeting serum urate <6 mg/dL. 1, 2

When NOT to Start ULT

• Do not initiate urate-lowering therapy after a first gout attack or in patients with infrequent attacks 1

First-Line ULT Options

• Xanthine oxidase inhibitors (allopurinol or febuxostat) are first-line options for urate-lowering therapy 1, 2, 3
• Start allopurinol at ≤100 mg/day and titrate gradually every 2-5 weeks to reach target serum urate <6 mg/dL 1, 2
• Allopurinol is preferred even in patients with moderate-to-severe chronic kidney disease 1

Alternative ULT Options

• Uricosuric agents (probenecid or benzbromarone) are alternatives in patients with normal renal function and no history of urolithiasis 1, 2, 3
• Consider HLA-B*5801 testing before initiating allopurinol in high-risk populations (Koreans with CKD, Han Chinese, or Thai) 2

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Mandatory Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis is mandatory when starting urate-lowering therapy to prevent flares. 1, 2

Prophylaxis Options

• Low-dose colchicine (0.5-0.6 mg once or twice daily) 1, 2
• Low-dose NSAIDs with gastroprotection if indicated 1, 2
• Low-dose prednisone 1, 3

Prophylaxis Duration

• Continue for at least 6 months, OR 1, 2
• 3 months after achieving target serum urate if no tophi are present, OR 1, 2
• 6 months after achieving target serum urate if tophi have resolved 1, 2

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Non-Pharmacologic Measures

• Weight loss is recommended for obese patients 1, 2, 3
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 1, 2
• Reduce intake of purine-rich foods (organ meats, shellfish) 1
• Encourage consumption of vegetables and low-fat or nonfat dairy products 1
• Address associated comorbidities including hyperlipidemia, hypertension, hyperglycemia, obesity, and smoking 1
• Consider losartan for hypertension and fenofibrate for hyperlipidemia, as both reduce serum uric acid levels 1

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Common Pitfalls and How to Avoid Them

• Delaying treatment beyond 24 hours reduces effectiveness—treat immediately upon symptom onset 1, 2
• Using high-dose colchicine regimens causes significant GI toxicity with no additional benefit—always use low-dose regimens 1, 2, 3
• Discontinuing ULT during acute flares worsens outcomes—continue established therapy 1, 2, 3
• Inadequate prophylaxis duration when initiating ULT leads to breakthrough flares and poor adherence—follow duration guidelines strictly 1, 2
• NSAIDs in high-risk patients: Avoid in heart failure, peptic ulcer disease, or significant renal disease 1, 2
• Colchicine drug interactions: Major interactions with strong CYP3A4 and P-glycoprotein inhibitors (cyclosporin, clarithromycin) require dose reduction or avoidance 1, 3, 4

Management of Inadequate Response

• Consider inadequate response if <20% improvement in pain within 24 hours or <50% improvement after 24 hours 1
• Switch to another monotherapy or add a second recommended agent 1
• For severe refractory attacks, IL-1 inhibitors (anakinra or canakinumab) may be considered, though off-label 1