What is the appropriate acute and long‑term management for an adult with typical acute gout presenting as a painful, swollen, erythematous first metatarsophalangeal joint?

Management of Acute Gout

For an adult presenting with a painful, swollen, erythematous first metatarsophalangeal joint consistent with acute gout, initiate anti-inflammatory therapy immediately—within 24 hours of symptom onset—using NSAIDs, corticosteroids, or low-dose colchicine as first-line options, and never discontinue any established urate-lowering therapy during the acute attack. 1

Acute Attack Management

First-Line Treatment Options

• NSAIDs are appropriate first-line therapy for most patients without contraindications, with full anti-inflammatory doses providing rapid pain relief 1, 2
• Corticosteroids (oral, intravenous, or intra-articular) are particularly valuable when NSAIDs or colchicine are contraindicated, with oral prednisone 30–40 mg daily for 5–7 days being highly effective 1
• Low-dose colchicine (1.2 mg loading dose, then 0.6 mg one hour later) is equally effective as high-dose regimens but with significantly fewer gastrointestinal adverse events 1, 3

Critical Timing and Treatment Principles

• Begin treatment within 24 hours of symptom onset for optimal outcomes 1
• Continue any established urate-lowering therapy without interruption during the acute flare—stopping allopurinol or febuxostat during an attack will prolong symptoms and undermine long-term control 1, 4
• Add topical ice and joint rest as adjunctive measures 1

Common Pitfall to Avoid

• Never use high-dose colchicine—it provides no additional benefit over low-dose regimens and significantly increases adverse events 1
• Avoid colchicine entirely in patients with severe renal impairment or those receiving strong P-glycoprotein or CYP3A4 inhibitors due to risk of fatal toxicity 1

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Long-Term Management of Recurrent Gout

Indications for Urate-Lowering Therapy

Absolute indications for starting urate-lowering therapy include: 1

• Any tophus or tophi on clinical exam or imaging
• Frequent attacks (≥2 per year)
• History of urolithiasis
• Chronic kidney disease
• Radiographic evidence of gouty arthropathy

Initiating Urate-Lowering Therapy

Allopurinol as First-Line Agent

• Start allopurinol at 100 mg/day for most patients (50 mg/day if chronic kidney disease stage 4 or worse) 1, 4
• Titrate upward every 2–5 weeks by 100 mg increments until serum uric acid is <6 mg/dL, with a maximum dose of 800 mg/day 1, 4
• The target serum uric acid is <6 mg/dL for all patients, with <5 mg/dL for those with tophi to promote crystal dissolution 1

Mandatory Prophylaxis When Starting ULT

• Simultaneously start prophylactic anti-inflammatory medication (low-dose colchicine 0.6 mg daily or NSAID) when initiating urate-lowering therapy to prevent acute flares 1, 4
• Continue prophylaxis for a minimum of 8 weeks and until the patient is attack-free with target serum uric acid achieved 1
• In patients with hepatic impairment, low-dose oral prednisone (5–10 mg daily) is the safest prophylactic option 1

Mechanism of Flare Prevention

• Mobilization of urate deposits from tissues during early ULT causes fluctuations in serum uric acid that trigger acute attacks—prophylaxis suppresses this inflammatory response 4
• Attacks typically become shorter and less severe after several months of therapy as the uric acid pool is depleted 4

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Algorithmic Approach to Management

For the Acute Attack:

1. Initiate anti-inflammatory therapy within 24 hours using NSAIDs, corticosteroids, or low-dose colchicine based on comorbidities 1
2. Continue any established urate-lowering therapy without interruption 1
3. Add topical ice and joint rest 1

For Long-Term Management:

1. Determine if ULT is indicated (≥2 attacks/year, tophi, urolithiasis, CKD, or radiographic damage) 1
2. Start allopurinol 100 mg/day (50 mg if CKD stage 4+) 1
3. Simultaneously start prophylaxis with low-dose colchicine or NSAID 1
4. Titrate allopurinol every 2–5 weeks by 100 mg until serum uric acid <6 mg/dL 1
5. Continue prophylaxis for minimum 8 weeks and until attack-free with target achieved 1

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Critical Pitfalls to Avoid

• Stopping urate-lowering therapy during acute attacks undermines long-term control and prolongs the current flare 1
• Starting ULT without prophylaxis virtually guarantees flares and treatment abandonment 1
• Inadequate allopurinol dose titration—many patients require doses well above 100 mg/day to achieve target serum uric acid 1
• Discontinuing ULT after symptoms resolve—gout is a chronic disease requiring indefinite therapy once indications are met 1
• Assuming septic arthritis is excluded based on clinical appearance alone—if infection cannot be ruled out, joint aspiration with Gram stain and culture is mandatory 1

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Lifestyle and Dietary Modifications

• Limit consumption of purine-rich foods (organ meats, shellfish) 3
• Avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 3
• Encourage consumption of vegetables and low-fat or nonfat dairy products 3
• Maintain fluid intake sufficient to yield daily urinary output of at least 2 liters 4
• Address modifiable risk factors including obesity, diuretic use, and hypertension 3, 5