From the Guidelines
The first-line treatment for acute gout is colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids, with the choice of drug based on the presence of contraindications, patient's previous experience with treatments, and the number and type of joints involved. According to the 2020 American College of Rheumatology guideline for the management of gout 1, colchicine, NSAIDs, or glucocorticoids are strongly recommended for the management of gout flares. For NSAIDs, options include naproxen (500mg twice daily), indomethacin (50mg three times daily), or celecoxib (100-200mg twice daily) for 7-10 days or until symptoms resolve. Colchicine should be started at a low dose, such as 1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily until attack resolves. 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 for treatment include:
- Starting treatment within 24 hours of symptom onset for maximum effectiveness
- Resting the affected joint, applying ice, and maintaining hydration during acute attacks
- Considering preventive therapy with allopurinol or febuxostat to lower uric acid levels for patients with frequent attacks, but not initiating during an acute attack
- The European League Against Rheumatism (EULAR) also recommends treating acute flares of gout as early as possible, with fully informed patients self-medicating at the first warning symptoms 2.
- It is essential to note that the choice of treatment should be individualized based on patient factors, such as comorbidities, medication interactions, and previous response to treatment.
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 3. 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 3.
From the Research
First-Line Treatment for Gout
- The first-line treatment for acute gout flares includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and oral or intramuscular corticosteroids 4, 5, 6, 7.
- For the prevention of recurrent gout, urate-lowering therapies such as allopurinol and febuxostat are recommended as first-line treatments 4, 5, 6.
- Uricosuric agents like probenecid can be used as adjuncts to urate-lowering therapies 4.
- Colchicine and/or probenecid can be reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective 5.
Treatment Options
- NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks 7.
- Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs 7.
- Oral colchicine is effective, with low-dose colchicine demonstrating a comparable tolerability profile as placebo and a significantly lower side effect profile to high-dose colchicine 7.
- IL-1 inhibitors like canakinumab can be effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 7.
Considerations
- Treatment should be personalized, taking into account comorbidities such as chronic kidney disease and ischemic heart disease, as well as patient preference 4.
- Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares 5.