Treatment for Gout

For acute gout attacks, initiate treatment within 24 hours using NSAIDs, low-dose colchicine, or corticosteroids as first-line monotherapy, selecting based on patient comorbidities. 1

Acute Gout Attack Management

General Principles

Start pharmacologic therapy within 24 hours of symptom onset to optimize outcomes and reduce pain more effectively 1
Continue established urate-lowering therapy (ULT) without interruption during an acute attack—do not stop ULT 1
Educate patients to self-initiate treatment at first warning symptoms ("pill in the pocket" approach) 2

First-Line Monotherapy Options (for mild-moderate attacks involving 1-3 small joints or 1-2 large joints)

NSAIDs:

Use full FDA-approved anti-inflammatory doses until the attack completely resolves 1
FDA-approved options include naproxen (Evidence A), indomethacin (Evidence A), and sulindac (Evidence B) 1
Avoid in patients with: chronic kidney disease (CrCl <30 mL/min), congestive heart failure, active peptic ulcer disease, cirrhosis, or on anticoagulation 1, 2, 3
Consider adding proton pump inhibitor for gastroprotection where indicated 1

Low-Dose Colchicine:

Dosing: 1.2 mg at onset, followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours) 1, 4
Most effective when started within 12-36 hours of symptom onset 1, 3
After initial dosing, can continue 0.6 mg twice daily beginning 12 hours later until attack resolves 1
Dose adjustments required for:
- Severe renal impairment (CrCl <30 mL/min): single 0.6 mg dose, repeat no more than once every 2 weeks 4
- Dialysis patients: single 0.6 mg dose, repeat no more than once every 2 weeks 4
- Severe hepatic impairment: repeat treatment course no more than once every 2 weeks 4
- Drug interactions with strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin): reduce dose or avoid 1, 2

Oral Corticosteroids:

Dosing: 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, 3
Alternative: Prednisone 30-35 mg/day for 3-5 days 2, 5
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, 5

Intra-articular Corticosteroid Injection:

Highly effective for single joint involvement 2, 3
Dose varies depending on joint size 1
Must exclude septic arthritis before injection 6

Combination Therapy (for severe pain ≥7/10 or polyarticular involvement ≥4 joints)

Appropriate combinations include: 1

Colchicine + NSAIDs at full doses
Oral corticosteroids + colchicine
Intra-articular steroids + any other modality

Common pitfall: The ACR task force did not vote on NSAIDs + systemic corticosteroids combination due to concerns about synergistic gastrointestinal toxicity 1

Special Populations

NPO (Nil Per Os) Patients:

For 1-2 affected joints: intra-articular corticosteroid injection (dose depends on joint size) 1, 2
For multiple joints: IV/IM methylprednisolone 0.5-2.0 mg/kg OR subcutaneous ACTH 25-40 IU 1, 2

Inadequate Response to Initial Therapy:

Defined as <20% pain improvement within 24 hours OR <50% improvement after 24 hours 1, 2, 3
Switch to another monotherapy or add a second recommended agent 1, 2

Adjunctive Non-Pharmacologic Measures

Apply topical ice to inflamed joint 1, 2, 3
Rest the affected joint 7

Long-Term Urate-Lowering Therapy (ULT)

Indications for Initiating ULT

Start ULT in patients with: 1, 2, 3

Recurrent acute gout attacks (≥2 per year)
Tophaceous gout
Chronic gouty arthropathy
Radiographic changes of gout
History of nephrolithiasis

Do NOT initiate ULT after a first gout attack or in patients with infrequent attacks 2

Target Serum Urate Level

Maintain serum urate <6 mg/dL (360 μmol/L) 1, 2, 3, 5

First-Line ULT Options

Allopurinol (Xanthine Oxidase Inhibitor):

Starting dose: ≤100 mg/day (50 mg/day if CrCl <30 mL/min or stage 4+ CKD) 2, 5
Titrate gradually every 2-5 weeks to achieve target serum urate <6 mg/dL 2
Can be used in patients with moderate-to-severe chronic kidney disease with appropriate dose adjustment 2

Febuxostat (Xanthine Oxidase Inhibitor):

Alternative to allopurinol 2, 3
Clinically equivalent efficacy 8

Uricosuric Agents (Probenecid, Benzbromarone):

Reserved for allopurinol-allergic patients or underexcretors with normal renal function and no history of urolithiasis 1, 7
Probenecid effective when CrCl >50 mL/min 6
Benzbromarone more effective than allopurinol but may be hepatotoxic 1

Anti-Inflammatory Prophylaxis During ULT Initiation

When to Initiate Prophylaxis

Start prophylaxis with or just prior to initiating ULT to prevent acute flares 1, 2, 5

First-Line Prophylaxis Options

Low-Dose Colchicine (Preferred):

Dosing: 0.5-0.6 mg once or twice daily 1, 2, 3
Adjust dose for renal impairment and drug interactions 1, 4
Severe renal impairment (CrCl <30 mL/min): start 0.3 mg/day 4
Dialysis patients: 0.3 mg twice weekly 4

Low-Dose NSAIDs (Alternative):

Example: Naproxen 250 mg twice daily 1
Add proton pump inhibitor where indicated 1, 2

Low-Dose Prednisone (Second-Line):

Dosing: <10 mg/day 1
Use only if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1
Caution: Doses >10 mg/day voted inappropriate by ACR task force 1
Monitor risk-benefit ratio carefully with continued use 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 (<6 mg/dL) in patients without tophi, OR
6 months after achieving target serum urate AND resolution of tophi in patients with history of tophi

Lifestyle Modifications and Comorbidity Management

Dietary Recommendations

Reduce intake of: organ meats, shellfish, alcoholic drinks (especially beer), beverages sweetened with high-fructose corn syrup 1, 2, 3, 9
Encourage consumption of: vegetables, low-fat or nonfat dairy products 1, 2, 9
Weight loss for obese patients 1, 2, 3

Medication Adjustments

Discontinue diuretics if possible (increase uric acid levels) 1, 9
Consider losartan for hypertension (increases urinary uric acid excretion) 2, 9, 6
Consider fenofibrate for hyperlipidemia (reduces serum uric acid) 2, 6

Comorbidity Screening

Screen all gout patients for cardiovascular risk factors and optimize treatment 2
Address hyperlipidemia, hypertension, hyperglycemia, obesity, and smoking 2

Critical Pitfalls to Avoid

Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 2, 3
Discontinuing ULT during acute attacks worsens outcomes and prolongs disease activity 1
Failing to provide prophylaxis when initiating ULT leads to acute flares and poor medication adherence 1, 2
Using high-dose colchicine regimens causes significant GI toxicity with no additional benefit compared to low-dose regimens 1, 2
Inadequate duration of prophylaxis results in breakthrough flares 1, 2
Not adjusting colchicine dose for renal impairment or drug interactions can cause serious toxicity 1, 2, 4
Using NSAIDs in high-risk patients (heart failure, CKD, peptic ulcer disease) increases morbidity 1, 2, 3

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