From the Guidelines
The first-line treatment for gout is nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or corticosteroids, with allopurinol as the preferred first-line urate-lowering therapy (ULT) for long-term management. For acute gout attacks, options include naproxen (500mg twice daily), indomethacin (50mg three times daily), or celecoxib (100-200mg twice daily) for 7-10 days 1. Colchicine should be started at 1.2mg at first sign of attack, followed by 0.6mg one hour later, then 0.6mg once or twice daily until symptoms resolve. Corticosteroids like prednisone (30-40mg daily for 3-5 days, then tapered over 7-10 days) are effective alternatives, especially for patients with contraindications to NSAIDs or colchicine.
Key Considerations
- Rest, ice application, and elevation of the affected joint provide symptomatic relief.
- Adequate hydration and avoiding alcohol and purine-rich foods during attacks are important supportive measures.
- Treatment should begin within 24 hours of symptom onset for maximum effectiveness.
- For long-term management, allopurinol is recommended as the first-line ULT, with a low starting dose (≤100 mg/day) and subsequent dose titration to target a serum urate level of <6 mg/dL 1.
Urate-Lowering Therapy
- Allopurinol is the preferred first-line ULT, including for patients with moderate-to-severe chronic kidney disease (CKD) 1.
- Febuxostat is an alternative option for patients who cannot tolerate allopurinol.
- The goal of ULT is to maintain a serum urate level of <6 mg/dL, with dose titration guided by serial serum urate measurements.
Prophylaxis
- Concomitant anti-inflammatory prophylaxis therapy (e.g., colchicine, NSAIDs, prednisone/prednisolone) is recommended for at least 3-6 months when initiating ULT 1.
From the FDA Drug Label
The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The first line treatment for gout is allopurinol (PO), with a dosage that varies depending on the severity of the disease, ranging from 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout 2. Key points to consider when initiating allopurinol therapy include:
- Starting with a low dose of 100 mg daily and increasing at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained
- Not exceeding the maximal recommended dosage of 800 mg daily
- Monitoring serum uric acid levels to adjust the dosage as needed
- Considering the use of uricosuric agents concurrently to reduce serum uric acid to normal or near-normal levels 2.
From the Research
First-Line Treatment for Gout
- The first-line treatment for gout flares includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and oral or intramuscular corticosteroids 3, 4, 5.
- IL-1 inhibitors are also considered a first-line option for flare refractory to standard therapies 3.
- For urate-lowering therapy, allopurinol and febuxostat are the initial treatments, with uricosuric agents such as probenecid, sulfinpyrazone, and benzbromarone used as adjuncts 3, 4, 5.
Pharmacotherapies for Gout Flares
- NSAIDs are commonly used to treat acute gout, with low-certainty evidence suggesting they may improve pain at 24 hours and have little to no effect on function, inflammation, or adverse events 6.
- Colchicine is also effective in treating gout flares, with moderate-certainty evidence showing it is probably equally beneficial to NSAIDs in terms of pain relief and improvement in function 6.
- Glucocorticoids are another option for treating gout flares, with moderate-certainty evidence showing they are probably equally beneficial to NSAIDs in terms of pain relief, improvement in function, and treatment success 6.
Urate-Lowering Therapies
- Allopurinol is an agent of first choice for urate-lowering therapy, but screening for HLA*B58:01 mutation is recommended in certain populations to decrease the occurrence of allopurinol hypersensitivity syndrome 5.
- Febuxostat is another efficacious urate-lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety 5.
- Novel uricosurics, such as verinurad and arhalofenate, are being developed as potential treatments for gout 5.