What is the recommended acute‑attack treatment and long‑term urate‑lowering strategy for an adult with gout without severe renal impairment, cardiovascular disease, or peptic ulcer disease?

Gout Management: Acute Treatment and Long-Term Urate-Lowering Strategy

Acute Gout Attack Treatment

Initiate pharmacologic therapy within 24 hours of symptom onset using NSAIDs, oral colchicine, or corticosteroids as equally appropriate first-line monotherapy options, with selection based on patient-specific factors. 1

First-Line Agent Selection Algorithm

Choose your acute treatment based on the following hierarchy:

• NSAIDs (naproxen, indomethacin, or sulindac): Use full FDA-approved anti-inflammatory doses and continue throughout the entire attack until complete resolution. 1, 2 No evidence suggests one NSAID is superior to another. 1, 2

• Oral colchicine: Administer 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg), then after 12 hours resume 0.6 mg once or twice daily until attack resolves. 1, 2 This regimen is only effective if started within 36 hours of symptom onset. 1, 2

• Oral corticosteroids: Prescribe prednisone 0.5 mg/kg per day (or prednisolone 30–35 mg daily) for 5–10 days at full dose then stop, or taper over 7–10 days. 1, 2

Severe or Polyarticular Attacks

For attacks involving ≥4 joints or multiple large joints, initiate combination therapy with colchicine + NSAID, or oral corticosteroid + colchicine. 1, 2 Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity. 1, 2

Critical Timing Considerations

Delaying treatment beyond 24 hours markedly reduces efficacy of any acute therapy. 1, 2 Colchicine effectiveness drops sharply after 36 hours from symptom onset and should not be initiated beyond this window. 1, 2

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Long-Term Urate-Lowering Therapy (ULT)

Indications for Initiating ULT

Do not initiate ULT after a first gout attack unless high-risk features are present. 1

Strongly indicated (start ULT) when any of the following are present:

• Subcutaneous tophi 1
• Radiographic joint damage attributable to gout 1
• Chronic kidney disease stage ≥3 1
• Recurrent attacks (≥2 episodes per year) 1

Conditionally indicated (discuss with patient) when:

• Serum urate >9 mg/dL 1
• Young age at disease onset 1
• Patient preference for early intervention 1

Allopurinol Initiation and Titration Protocol

Start allopurinol at 100 mg daily and increase by 100 mg every 2–4 weeks until serum uric acid <6 mg/dL is achieved, without exceeding 800 mg per day. 1, 3

The therapeutic goal is to maintain serum uric acid below 360 μmol/L (6 mg/dL) to promote crystal dissolution and prevent crystal formation. 1 This target reflects a tissue level below the saturation point for monosodium urate. 1

Mandatory Prophylaxis During ULT Initiation

Provide anti-inflammatory prophylaxis with low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAID when starting or adjusting ULT. 1, 2, 3

Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi are present. 1, 2 If tophi are present, continue for 6 months after achieving target serum urate. 1, 2

High-quality evidence demonstrates that prophylactic colchicine or NSAIDs significantly reduce acute gout flares during the first 6 months of ULT initiation. 1, 2

Monitoring and Dose Adjustment

Use serum uric acid levels as an index for dosage adjustment, checking every 2–4 weeks during titration and every 6 months once target is achieved. 1, 4 In patients with pre-existing renal disease, monitor BUN and creatinine during early stages of allopurinol therapy. 3

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Management of Ongoing ULT During Acute Flares

Do not discontinue established urate-lowering therapy when an acute gout attack occurs. 1, 2 Continuation maintains serum urate control and does not worsen the attack. 1, 2

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Common Pitfalls to Avoid

• Never delay acute treatment beyond 24 hours—efficacy drops markedly. 1, 2
• Never start colchicine after 36 hours from symptom onset—it will be ineffective. 1, 2
• Never interrupt allopurinol during an acute flare—this destabilizes urate levels. 1, 2
• Never start ULT during an acute attack—wait until the flare resolves, then initiate with prophylaxis. 1, 5
• Never use high-dose colchicine regimens (>1.8 mg in first hour)—they provide no additional benefit but substantially increase gastrointestinal toxicity. 1, 2