From the Guidelines
Gout evaluation and treatment should prioritize prompt diagnosis and management with urate-lowering therapy (ULT) and anti-inflammatory medications, as well as lifestyle modifications to reduce serum uric acid levels and prevent flares, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
Diagnosis and Treatment
For diagnosis, joint aspiration with crystal analysis showing negatively birefringent monosodium urate crystals is the gold standard, though elevated serum uric acid levels (>6.8 mg/dL) and clinical presentation with acute monoarticular arthritis (often affecting the first metatarsophalangeal joint) can support diagnosis.
- For acute gout attacks, treatment should begin within 24 hours using:
- NSAIDs (such as naproxen 500mg twice daily or indomethacin 50mg three times daily for 3-5 days)
- Colchicine (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until resolution)
- Corticosteroids (prednisone 30-40mg daily tapered over 7-10 days)
Long-term Management
For long-term management, urate-lowering therapy is indicated for patients with:
- Frequent attacks (>2 yearly)
- Tophi
- Joint damage
- Kidney stones
- Allopurinol is first-line (starting at 100mg daily, gradually increasing to achieve target uric acid <6 mg/dL) or febuxostat (40-80mg daily) for those intolerant to allopurinol
- Prophylaxis with colchicine (0.6mg daily) or low-dose NSAIDs should be used when initiating urate-lowering therapy for 3-6 months to prevent flares
Lifestyle Modifications
Lifestyle modifications including:
- Weight loss
- Limiting alcohol (especially beer)
- Reducing purine-rich foods (red meat, seafood)
- Avoiding high-fructose corn syrup can help manage gout long-term, as supported by the 2016 updated EULAR evidence-based recommendations for the management of gout 1 and the 2020 American College of Rheumatology guideline for the management of gout 1.
From the FDA Drug Label
The evidence for the efficacy of colchicine in patients with chronic gout is derived from the published literature. Two randomized clinical trials assessed the efficacy of colchicine 0. 6 mg twice a day for the prophylaxis of gout flares in patients with gout initiating treatment with urate-lowering therapy. In both trials, treatment with colchicine decreased the frequency of gout flares. The efficacy of a low-dosage regimen of oral colchicine (total dose 1. 8 mg over one hour) for treatment of gout flares was assessed in a multicenter, randomized, double-blind, placebo-controlled, parallel group, one week, dose-comparison study. Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis. Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis.
Gout Evaluation and Treatment:
- Colchicine 2 is used for the prophylaxis of gout flares in patients with gout initiating treatment with urate-lowering therapy, and for the treatment of gout flares.
- Indomethacin 3 is used for relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis.
- Probenecid 4 is used for the treatment of the hyperuricemia associated with gout and gouty arthritis. The treatment of gout involves the use of medications such as colchicine, indomethacin, and probenecid, which can help to reduce the frequency of gout flares, relieve pain and inflammation, and lower uric acid levels.
From the Research
Gout Evaluation
- Gout is characterized by painful joint inflammation, most commonly in the first metatarsophalangeal joint, resulting from precipitation of monosodium urate crystals in a joint space 5
- Gout is typically diagnosed using clinical criteria from the American College of Rheumatology 5
- Diagnosis may be confirmed by identification of monosodium urate crystals in synovial fluid of the affected joint 5
Gout Treatment
- Acute gout may be treated with nonsteroidal anti-inflammatory drugs, corticosteroids, or colchicine 5, 6
- To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods and avoid alcoholic drinks and beverages sweetened with high-fructose corn syrup 5
- The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid 5
- Reduction of uric acid levels is key to avoiding gout flares 5, 7, 8
- Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 5, 7, 8
- Colchicine and/or probenecid are reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective 5
- Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares 5
Treatment Options
- Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout 9
- Cyclo-oxygenase-2 (COX-2) inhibitors (COXIBs) are also effective in treating acute gout 9
- Glucocorticoids are effective in treating acute gout, especially in patients who cannot tolerate NSAIDs or colchicine 9, 6
- IL-1β antagonists, such as canakinumab, are effective in treating acute gout, especially in patients who are refractory to or have contraindications to NSAIDs and/or colchicine 6
- Novel therapies, such as verinurad and arhalofenate, are being developed for the treatment of gout 8
- Pegloticase is effective in treating patients with recalcitrant gout, but its immunogenicity can limit its efficacy 8