What is the recommended management of gout, including treatment of acute flares, urate‑lowering therapy, prophylaxis, and lifestyle modifications?

Management of Gout

For acute gout flares, use NSAIDs, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or corticosteroids as first-line therapy; initiate urate-lowering therapy with allopurinol (starting at 100 mg daily or 50 mg if CKD stage ≥4) in patients with recurrent attacks (≥2/year), tophi, or radiographic damage, titrating to achieve serum urate <6 mg/dL; and provide mandatory colchicine prophylaxis (0.5-1 mg daily) for at least 6 months when starting urate-lowering therapy. 1

Acute Gout Flare Management

First-line treatment options include:

• NSAIDs at full anti-inflammatory doses should be initiated immediately for acute attacks, with choice guided by comorbidities 1, 2
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is equally effective as higher doses but causes fewer gastrointestinal adverse effects 1
• Corticosteroids (oral, intra-articular, or intramuscular) are particularly useful when NSAIDs and colchicine are contraindicated 1, 2

Important caveat: Colchicine is contraindicated in patients with renal or hepatic impairment who are using potent cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors 1

Indications for Urate-Lowering Therapy

Strong indications (must initiate ULT):

• Recurrent gout attacks (≥2 per year) 1
• One or more subcutaneous tophi 1, 3, 2
• Radiographic damage attributable to gout 1, 3
• Chronic kidney disease stage ≥3 3, 2

Conditional indications (consider ULT after first flare):

• Serum urate >9 mg/dL 3
• History of urolithiasis 3, 2
• Young age (<40 years) with significant comorbidities (hypertension, ischemic heart disease, heart failure) 3

Do NOT initiate ULT:

• After a first gout attack in patients with infrequent attacks (<2/year) and no high-risk features 1
• For asymptomatic hyperuricemia alone 1, 3

Urate-Lowering Therapy Protocol

Allopurinol is the first-line agent for all patients:

• Starting dose: 100 mg daily (or 50 mg daily if CKD stage ≥4) 1, 3, 2
• Titration: Increase by 100 mg every 2-5 weeks until serum urate <6 mg/dL is achieved 1, 3, 2
• Maximum dose: 800 mg daily 3
• Target serum urate: <6 mg/dL for all patients; <5 mg/dL for severe gout with tophi or chronic arthropathy 1, 2

Alternative agents if allopurinol fails or is not tolerated:

• Febuxostat (40 mg daily, can increase to 80 mg) is equally effective at lowering serum urate 1, 2
• Uricosuric agents (probenecid, benzbromarone) if eGFR >50 mL/min 1, 3
• Pegloticase (uricase) reserved only for severe refractory tophaceous gout where all other therapies have failed 1, 3

Mandatory Flare Prophylaxis During ULT Initiation

This is critical to prevent treatment failure and non-adherence:

• Colchicine 0.5-1 mg daily for at least 6 months when initiating or escalating ULT 1, 3, 2
• Alternative prophylaxis: Low-dose NSAIDs or low-dose glucocorticoids if colchicine is contraindicated or not tolerated 1, 3
• Duration: Continuing prophylaxis beyond 8 weeks is more effective than shorter durations 1

Common pitfall: Stopping prophylaxis before 6 months significantly increases breakthrough flare risk and contributes to patient non-adherence 3, 4

Monitoring Strategy

During ULT titration:

• Check serum urate every 2-5 weeks during dose escalation 3, 2
• Continue titration until target <6 mg/dL is achieved 1, 2

Once at target:

• Monitor serum urate every 6 months 3, 2
• Monitor frequency of gout attacks and tophi size 1

Important principle: Do NOT stop ULT during an acute flare; continue therapy and add anti-inflammatory treatment 3

Lifestyle Modifications

Dietary and lifestyle changes should be implemented for all patients:

• Reduce excess body weight and perform regular exercise 1, 2
• Avoid excess alcohol (especially beer and spirits) and sugar-sweetened beverages 1, 2
• Limit purine-rich organ meats and shellfish 2, 5
• Encourage low-fat dairy products 2
• Eliminate non-essential medications that elevate uric acid (thiazide/loop diuretics, niacin) 2

Caveat: Low-dose aspirin (≤325 mg daily) can be continued for cardiovascular prophylaxis despite modest urate-elevating effects 3

Assessment of Comorbidities

At diagnosis, evaluate:

• Renal function (eGFR/creatinine clearance) to guide allopurinol dosing 1, 2
• Cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, coronary disease) 1, 2
• For gout onset before age 25 or history of kidney stones: obtain 24-hour urine uric acid to screen for overproduction 2

Management of Tophi

Medical management is primary:

• Achieve sustained serum urate reduction, preferably <5 mg/dL (0.30 mmol/L) 1, 2
• Surgery is indicated only in selected cases (nerve compression, mechanical impingement, infection) 1

Duration of ULT

ULT should be continued indefinitely in most patients:

• Serum urate <6 mg/dL should be maintained lifelong once ULT is initiated 3
• Discontinuation might be considered only in highly selected patients after ≥5 years of continuous ULT with serum urate consistently <6 mg/dL and no flares for 2-3 years, but this remains an area of inconclusive evidence 1, 3