What is the management and treatment plan for a patient presenting with gout?

Management and Treatment of Gout

Gout management requires a dual approach: immediate treatment of acute flares with anti-inflammatory agents and long-term urate-lowering therapy to prevent recurrence and complications, with patient education being the cornerstone of successful outcomes. 1

Patient Education and Initial Assessment

• Every patient with gout must be fully informed about disease pathophysiology, the existence of curative treatments, and the necessity of lifelong serum urate lowering below target levels. 1
• Systematically screen all patients for cardiovascular risk factors, renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidemia, hypertension, diabetes, and smoking status. 1
• Measure renal function in all patients, as this directly impacts medication selection and dosing. 1

Acute Gout Flare Management

First-Line Treatment Selection

Initiate treatment within 12-24 hours of symptom onset—early initiation is the single most critical determinant of success, not which agent is chosen. 2, 3

Three equally effective first-line options exist: 2, 3

• Colchicine: Loading dose of 1 mg followed by 0.5 mg one hour later (maximum 1.8 mg over one hour), most effective when started within 12 hours of flare onset 1, 2
• NSAIDs: Full FDA-approved anti-inflammatory doses with proton pump inhibitor if appropriate 1
• Oral corticosteroids: Prednisone 30-35 mg daily (or equivalent) for 3-5 days 1, 2

Treatment Selection Algorithm Based on Comorbidities

For patients with renal impairment, cardiovascular disease, heart failure, or peptic ulcer disease, oral corticosteroids are the safest first-line option. 2, 3

• Avoid colchicine in severe renal impairment (CrCl <30 mL/min) or in patients on strong CYP3A4/P-glycoprotein inhibitors (cyclosporin, clarithromycin) due to risk of fatal toxicity. 1, 4
• Avoid NSAIDs in patients with severe renal impairment, uncontrolled hypertension, cardiac failure, or peptic ulcer disease. 1

For monoarticular or oligoarticular flares (1-2 large joints), intra-articular corticosteroid injection is highly effective and preferred. 2, 3

For patients with contraindications to all first-line agents and frequent flares, IL-1 blockers (canakinumab 150 mg subcutaneously) should be considered, but current infection is an absolute contraindication. 1, 2

Critical Management During Acute Flare

Continue any established urate-lowering therapy without interruption during the acute flare—stopping it worsens the flare and complicates long-term management. 2, 3

Urate-lowering therapy can be started during an acute flare with appropriate anti-inflammatory coverage. 2, 3

Long-Term Urate-Lowering Therapy (ULT)

Indications for ULT

Initiate ULT in patients with: 3

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

Target Serum Urate Level

The treatment target is serum urate below 6 mg/dL (0.36 mmol/L) to achieve dissolution of monosodium urate crystals and eventual absence of gout attacks. 1, 3

For patients with tophi, target serum urate below 5 mg/dL (0.30 mmol/L) to achieve sustained reduction and resolution. 1

First-Line ULT Agent

Allopurinol is the preferred first-line urate-lowering agent. 1, 2, 3, 5

Allopurinol dosing strategy: 5

• Start at ≤100 mg daily (50-100 mg in renal impairment)
• Titrate gradually every 2-5 weeks by 100 mg increments
• Target dose: 200-300 mg daily for mild gout, 400-600 mg daily for moderately severe tophaceous gout
• Maximum dose: 800 mg daily
• Adjust for renal function: CrCl 10-20 mL/min use 200 mg daily; CrCl <10 mL/min use maximum 100 mg daily

Alternative ULT Agents

If allopurinol is contraindicated or not tolerated, consider: 1, 2

• Febuxostat (can be used without dose adjustment in mild-moderate renal impairment) 1
• Uricosurics (benzbromarone, probenecid) in patients with preserved renal function and no history of nephrolithiasis 1
• Uricase (pegloticase) only for severe gout where all other therapies have failed or are contraindicated 1

Important caveat: Febuxostat carries increased risk of cardiovascular death and heart failure hospitalization, limiting its use in patients with cardiovascular disease. 6

Mandatory Flare Prophylaxis During ULT Initiation

All patients starting ULT must receive concomitant anti-inflammatory prophylaxis for at least 3-6 months to prevent treatment-induced flares. 1, 2, 3

First-line prophylaxis options: 1, 2

• Colchicine 0.5-1 mg daily (reduce dose in renal impairment to 0.3 mg twice weekly for dialysis patients) 1, 4
• Low-dose NSAIDs with gastroprotection (if colchicine contraindicated) 1
• Low-dose prednisone (<10 mg/day) (if both colchicine and NSAIDs contraindicated) 1

Continue prophylaxis for at least 3-6 months after achieving target serum urate, or longer if flares persist. 2, 3

Critical warning: Patients on statins receiving colchicine prophylaxis should be monitored for neurotoxicity and muscular toxicity. 1

Lifestyle Modifications

Strongly recommend the following lifestyle changes: 1, 3

• Weight loss for overweight/obese patients
• Avoid alcohol, especially beer and spirits
• Avoid sugar-sweetened beverages and high-fructose corn syrup
• Limit purine-rich foods (organ meats, shellfish, excessive meat and seafood)
• Encourage low-fat or nonfat dairy products
• Encourage regular exercise
• Smoking cessation

Management of Tophi

Tophi should be treated medically by achieving sustained serum uric acid reduction below 5 mg/dL (0.30 mmol/L). 1

Surgery is only indicated in selected cases: nerve compression, mechanical impingement, or infection. 1

Monitoring Strategy

Monitor serum urate levels, frequency of gout attacks, and tophi size regularly. 1

Maintain fluid intake sufficient to yield daily urinary output of at least 2 liters, with neutral or slightly alkaline urine. 5

Comorbidity-Specific Considerations

For hypertensive patients, consider losartan (increases urinary uric acid excretion). 3

For hyperlipidemic patients, consider fenofibrate. 3

Avoid loop and thiazide diuretics when possible, as they increase uric acid levels. 7

Common Pitfalls to Avoid

• Never delay treatment initiation for acute flares—this is the most critical error. 2
• Never stop urate-lowering therapy during an acute flare. 2, 3
• Never use colchicine in severe renal impairment or with strong CYP3A4/P-glycoprotein inhibitors. 1, 2
• Never use NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease. 2
• Never treat asymptomatic hyperuricemia pharmacologically—it is not recommended to prevent gouty arthritis, renal disease, or cardiovascular events. 1
• Never initiate ULT without concurrent anti-inflammatory prophylaxis. 1, 2, 3