What is the treatment for an adult patient diagnosed with gout?

Treatment of Gout in Adults

For acute gout flares, use oral colchicine (low-dose), NSAIDs, or glucocorticoids as first-line therapy based on patient contraindications and comorbidities, and initiate urate-lowering therapy after the flare resolves in patients with recurrent attacks (≥2 per year), tophi, or chronic gouty arthropathy. 1

Acute Gout Flare Management

First-Line Pharmacologic Options

The 2020 American College of Rheumatology guidelines strongly recommend three equally effective first-line options for acute flares 1:

• Oral colchicine (low-dose): 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over 1 hour). Low-dose colchicine has similar efficacy to high-dose with fewer adverse effects 1

• NSAIDs: Any NSAID at full anti-inflammatory dose (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily). The key to success is early initiation within 24 hours of symptom onset, not which specific NSAID is chosen 1, 2

• Glucocorticoids:

  • Oral prednisone 0.5 mg/kg/day (approximately 30-35 mg daily) for 5-10 days without taper, OR 2-5 days at full dose followed by 7-10 day taper 1, 3
  • Intramuscular triamcinolone acetonide 60 mg for patients unable to take oral medications 1, 3
  • Intra-articular injection for monoarticular or oligoarticular involvement of accessible large joints 1, 3

Selecting Among First-Line Options

Choose glucocorticoids preferentially in patients with: 1, 3

• Severe renal impairment (eGFR <30 mL/min) - NSAIDs risk acute kidney injury; colchicine has fatal toxicity risk
• Cardiovascular disease or heart failure - NSAIDs carry cardiovascular risks
• Cirrhosis or hepatic impairment - NSAIDs contraindicated
• Active peptic ulcer disease or GI bleeding history - NSAIDs increase bleeding risk
• Anticoagulation therapy - NSAIDs increase bleeding risk

Avoid colchicine in: 1, 3

• Severe renal impairment (requires significant dose reduction; toxicity risk substantially increased)
• Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (macrolides, azole antifungals)

Avoid NSAIDs in: 1, 3

• Chronic kidney disease (can exacerbate or cause acute kidney injury)
• Heart failure or cardiovascular disease
• Active peptic ulcer disease

Second-Line and Adjunctive Therapies

• IL-1 inhibitors (canakinumab, anakinra): Conditionally recommended only when colchicine, NSAIDs, and glucocorticoids are all contraindicated or poorly tolerated. The ACR strongly recommends against using IL-1 inhibitors as first-line due to cost and lack of superiority over standard therapies 1

• Topical ice: Conditionally recommended as adjuvant treatment when other anti-inflammatory therapies are poorly tolerated or contraindicated 1

• Combination therapy: For severe polyarticular flares, consider combining oral glucocorticoids with colchicine, or intra-articular steroids with any oral modality 3

Monitoring Acute Treatment Response

Inadequate response is defined as <20% pain improvement within 24 hours OR <50% improvement at ≥24 hours after initiating therapy 3. If inadequate response occurs, consider combination therapy or switching to alternative first-line agent 3.

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate ULT in patients with 1, 4, 5:

• ≥2 gout flares per year
• Presence of tophi (subcutaneous or imaging-detected)
• Chronic gouty arthropathy or radiographic joint damage
• Urolithiasis
• Chronic kidney disease with gout

First-Line ULT Agent

Allopurinol is the preferred first-line agent 1, 4:

• Start at 100 mg daily (50 mg daily if CKD stage 4 or worse)
• Titrate by 100 mg every 2-4 weeks based on serum uric acid levels
• Target serum uric acid <6 mg/dL for most patients; <5 mg/dL for patients with tophi 4
• Maximum dose: 800-900 mg daily (adjust for renal function)

Important caveat: Screen for HLA-B*5801 allele in high-risk populations (Korean, Han Chinese, Thai descent) before starting allopurinol due to severe cutaneous adverse reaction risk 4

Alternative ULT Agents

• Febuxostat: Use if allopurinol is contraindicated, not tolerated, or ineffective. Start 40 mg daily, increase to 80 mg if needed. Note: Associated with increased all-cause and cardiovascular mortality compared to allopurinol; avoid in patients with cardiovascular disease 5

• Probenecid (uricosuric): 500 mg twice daily, increase to 1000 mg twice daily if needed. Use only in patients with normal renal function (eGFR >50 mL/min), no history of kidney stones, and documented uric acid underexcretion 2, 4

Flare Prophylaxis During ULT Initiation

Mandatory prophylaxis for 3-6 months when starting ULT to prevent mobilization flares 1, 6:

First-line options:

• Low-dose colchicine 0.5-0.6 mg once or twice daily 1, 6
• Low-dose NSAID (naproxen 250 mg twice daily) 6

Second-line option:

• Low-dose prednisone <10 mg daily if colchicine and NSAIDs contraindicated 1, 3, 6

Critical point: Do NOT use high-dose prednisone (>10 mg/day) for prophylaxis 3

Lifestyle and Dietary Modifications

The ACR conditionally recommends for all patients with gout 1:

• Limit alcohol intake (especially beer and spirits)
• Limit high-fructose corn syrup consumption
• Limit purine-rich foods (red meat, organ meats, certain seafood)
• Weight loss for overweight/obese patients
• Switch from hydrochlorothiazide to alternative antihypertensive when feasible
• Preferentially choose losartan as antihypertensive when appropriate
• Do NOT stop low-dose aspirin for cardiovascular indications 1

Common Pitfalls to Avoid

• Never interrupt ongoing ULT during an acute flare - continue the urate-lowering medication 3
• Do not start ULT during an acute flare - wait until the flare resolves, then initiate with prophylaxis 6
• Do not use serum uric acid level alone to diagnose acute gout - levels may be normal during acute attacks 7
• Do not delay treatment initiation - efficacy decreases significantly if treatment is not started within 24 hours of symptom onset 3, 2
• Do not use standard-dose colchicine in renal impairment without significant dose reduction 3
• Do not assume all patients need ULT - it is not indicated for asymptomatic hyperuricemia 8

When to Refer to Rheumatology

Refer patients to a rheumatologist when 9:

• Unclear etiology of hyperuricemia despite appropriate workup
• Refractory disease with persistent symptoms despite appropriate first-line therapy
• Frequent flares (≥2 per year) continuing despite standard management
• Difficulty achieving target serum uric acid, particularly with renal impairment
• Multiple or serious adverse events from urate-lowering therapy
• Severe tophaceous disease requiring aggressive management
• Complex comorbidity management requiring coordination between specialists