Treatment of Gout
Acute Gout Attack Management
For acute gout attacks, initiate treatment within 24 hours of symptom onset with NSAIDs, low-dose colchicine, or corticosteroids as first-line monotherapy, selecting based on patient comorbidities and contraindications. 1
First-Line Treatment Options
NSAIDs:
- Use any NSAID at full anti-inflammatory doses—no single agent is superior to another 2
- FDA-approved options include naproxen and indomethacin 2
- Continue at full dose until the acute attack completely resolves 2
- Critical contraindications: Avoid in patients with chronic kidney disease, congestive heart failure, peptic ulcer disease, or cirrhosis 2, 1, 3
Low-Dose Colchicine:
- Dosing regimen: 1.2 mg at onset, followed by 0.6 mg one hour later (maximum 1.8 mg in first 12 hours) 2, 1
- Most effective when started within 12 hours of symptom onset, but can be used up to 36 hours 1, 3
- Dose adjustments for renal impairment: 4
- Drug interactions: Reduce dose or avoid with strong CYP3A4 and P-glycoprotein inhibitors (e.g., cyclosporin, clarithromycin) 2, 4
- High-dose colchicine regimens cause significant GI toxicity with no additional benefit—always use low-dose regimens 2, 1, 3
Oral Corticosteroids:
- Dosing options: 1, 3
- Prednisone 30-35 mg/day for 3-5 days, then stop OR
- 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
- Particularly useful for patients with contraindications to NSAIDs or colchicine 2, 3
- Safest option in patients with renal impairment 2, 3
- Avoid in: Patients with diabetes, active infection, or high infection risk 3
Intra-articular Corticosteroid Injection:
Combination Therapy for Severe Attacks
For severe pain (≥7/10) or polyarticular involvement, consider combination therapy: 2
- Colchicine plus NSAIDs
- Oral corticosteroids plus colchicine
- Intra-articular steroids with any other modality
Critical Management Principles
Continue established urate-lowering therapy (ULT) without interruption during acute attacks—do not stop ULT. 2, 1 Discontinuing ULT during acute flares worsens outcomes and prolongs disease activity. 1
Educate patients to self-initiate treatment at first warning symptoms ("pill in the pocket" approach). 2, 1 Delaying treatment beyond 24 hours significantly reduces effectiveness. 1
Topical ice application is appropriate as an adjunctive measure to pharmacologic therapy. 2
Long-Term Urate-Lowering Therapy (ULT)
Indications for Initiating ULT
Initiate ULT in patients with: 2, 3
- Recurrent acute attacks (≥2 attacks per year)
- Tophaceous gout
- 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). 2, 1, 3
First-Line ULT Options
Allopurinol (preferred first-line agent): 2, 1, 3
- Starting dose: ≤100 mg/day 2, 1
- For severe CKD (CrCl <30 mL/min or stage 4+ CKD): Start at 50 mg/day 1, 3
- Titrate gradually every 2-5 weeks to reach target serum urate <6 mg/dL 2
- Titrate to target, not to a standard dose 2
Febuxostat (alternative to allopurinol): 2, 1
- Clinically equivalent efficacy to allopurinol 1
Uricosuric agents (probenecid, benzbromarone): 2
- Alternatives in patients with normal renal function and no history of urolithiasis 2
Anti-Inflammatory Prophylaxis During ULT Initiation
Mandatory prophylaxis must be started with or just prior to initiating ULT to prevent acute flares. 2, 1 Failing to provide prophylaxis leads to acute flares and poor medication adherence. 1
Prophylaxis Options
Low-dose colchicine (preferred): 2, 1, 3
Low-dose NSAIDs (alternative): 2, 1
- ≤10 mg/day for patients with contraindications to both colchicine and NSAIDs 1
Duration of Prophylaxis
Continue prophylaxis for: 2, 1, 3
- At least 6 months OR
- 3 months after achieving target serum urate if no tophi are present OR
- 6 months after achieving target serum urate AND resolution of tophi if tophi are present
Inadequate duration of prophylaxis results in breakthrough flares. 1
Lifestyle Modifications and Comorbidity Management
Dietary Recommendations
- Organ meats and shellfish (purine-rich foods)
- Alcoholic drinks, especially beer and spirits
- Beverages sweetened with high-fructose corn syrup
Encourage consumption of: 2, 1, 3
- Vegetables
- Low-fat or nonfat dairy products
Weight Management
Weight loss is recommended for obese patients. 2, 1, 3
Comorbidity Optimization
Screen all gout patients for cardiovascular risk factors and optimize treatment. 2, 1
Consider medication adjustments: 2
- Losartan for hypertension (reduces serum uric acid)
- Fenofibrate for hyperlipidemia (reduces serum uric acid)
- Avoid or minimize loop and thiazide diuretics when possible (increase uric acid levels)
Critical Pitfalls to Avoid
- Delaying treatment beyond 24 hours significantly reduces effectiveness 1
- Discontinuing ULT during acute attacks worsens outcomes 1
- Using high-dose colchicine causes significant GI toxicity with no benefit over low-dose regimens 2, 1, 3
- Not adjusting colchicine dose for renal impairment or drug interactions can cause serious toxicity 1, 4
- Inadequate duration of prophylaxis when initiating ULT leads to breakthrough flares 1
- Using NSAIDs in high-risk patients (heart failure, CKD, peptic ulcer disease) increases morbidity 1, 3