What are the common medications for gout management?

Common Medications for Gout Management

The most common drugs for gout are NSAIDs, corticosteroids, and low-dose colchicine for acute attacks, with allopurinol as the primary medication for long-term urate-lowering therapy. 1, 2

Acute Gout Attack Treatment

First-Line Monotherapy Options

Corticosteroids are recommended as first-line therapy for acute gout in patients without contraindications because they are safer, equally effective as NSAIDs, and low-cost. 1

• Oral corticosteroids: Prednisolone 30-35 mg daily for 5 days is effective and well-tolerated 3, 1, 2
• NSAIDs: Full anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) are effective when started promptly 3, 1, 2
• Low-dose colchicine: 1.2 mg followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) is as effective as high-dose regimens with significantly fewer gastrointestinal side effects—23% versus 77% reported diarrhea with low versus high doses 3, 1, 4

Key Safety Considerations

• NSAIDs should be avoided in patients with chronic kidney disease, heart failure, cirrhosis, or peptic ulcer disease 1, 2
• Corticosteroids should be avoided in patients with diabetes, active infection, or high infection risk 2
• Colchicine is most effective when started within 12 hours of symptom onset but can be used up to 36 hours 2

Combination Therapy

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

Long-Term Urate-Lowering Therapy (ULT)

Primary Medication: Allopurinol

Allopurinol is the first-line urate-lowering medication for chronic gout management. 5, 2, 6, 7

• Starting dose: 100 mg daily (50 mg daily in chronic kidney disease stage 4 or worse) 5, 2, 6
• Titration: Increase by 100 mg at weekly intervals until serum urate <6 mg/dL is achieved 1
• Target: Serum uric acid level below 6 mg/dL (357 μmol/L) 5, 2

Alternative Urate-Lowering Agent

• Febuxostat: A xanthine oxidase inhibitor that is clinically equivalent to allopurinol but has higher cost 1, 2

Uricosuric Agents

• Probenecid: Reserved for patients who cannot tolerate allopurinol or febuxostat, or in whom these agents are ineffective 8, 7
• These are preferred in allopurinol-allergic patients with normal renal function and no history of kidney stones 8

Prophylaxis During ULT Initiation

Anti-inflammatory prophylaxis is essential when starting urate-lowering therapy to prevent acute flares triggered by mobilization of urate crystals. 1, 2, 4

First-Line Prophylaxis Options

• Low-dose colchicine: 0.6 mg once or twice daily, adjusted for renal function 1, 2, 4
• Low-dose NSAIDs: Such as naproxen 250 mg twice daily 2, 9
• Low-dose corticosteroids: Prednisone ≤10 mg/day for patients with contraindications to both colchicine and NSAIDs 2

Duration of Prophylaxis

• Continue for at least 6 months after initiating ULT 1, 4, 7
• For patients without tophi: continue for the greater of 6 months or 3 months after achieving target serum urate 2
• For patients with tophi: continue for 6 months after achieving target serum urate and resolution of tophi 2

Common Pitfalls to Avoid

• Never use high-dose colchicine for acute gout—the low-dose regimen (1.2 mg then 0.6 mg one hour later) is equally effective with 77% fewer gastrointestinal adverse events 3
• Do not discontinue established ULT during an acute gout attack 5
• Do not start ULT during an acute attack; wait until the attack resolves 8
• Always provide prophylaxis when initiating ULT to prevent mobilization flares 1, 2, 4
• Adjust colchicine doses when used with CYP3A4 or P-glycoprotein inhibitors to avoid fatal toxicity 4