What is the recommended acute and long‑term treatment plan for an adult patient with gout?

Gout Treatment: Acute and Long-Term Management

Acute Gout Attack Management

For an acute gout flare, initiate anti-inflammatory therapy within 24 hours using NSAIDs, low-dose colchicine, or corticosteroids as first-line options, and never discontinue established urate-lowering therapy during the attack. 1

First-Line Anti-Inflammatory Options

All three first-line agents—NSAIDs, low-dose colchicine, and corticosteroids—provide equivalent pain relief with high-quality evidence supporting their use. 2 The choice depends on patient-specific contraindications rather than superiority of any single class. 1

Low-Dose Colchicine Regimen

• Administer 1.2 mg orally immediately, followed by 0.6 mg one hour later (total 1.8 mg). 1
• This low-dose regimen is equally effective as high-dose colchicine but causes significantly fewer gastrointestinal adverse events. 2, 1
• Colchicine must be started within 36 hours of symptom onset for optimal efficacy. 2, 1
• Avoid the outdated hourly dosing regimen (1.2 mg followed by 0.6 mg hourly), which provides no additional benefit but markedly increases toxicity. 1

NSAID Therapy

• Use any FDA-approved NSAID (naproxen, indomethacin, sulindac) at full anti-inflammatory dosing until the attack completely resolves. 1
• NSAIDs are contraindicated in severe renal impairment (eGFR <30 mL/min), active peptic ulcer disease, heart failure, and cirrhosis. 3

Corticosteroid Options

• Oral prednisone 0.5 mg/kg per day (typically 30-40 mg) for 5-10 days at full dose, then stop abruptly. 1, 3
• Alternative: 2-5 days at full dose followed by 7-10 day taper. 1, 3
• Intramuscular triamcinolone acetonide 60 mg as a single injection is appropriate when oral access is limited. 1, 3
• Intra-articular corticosteroid injection is especially valuable for monoarticular attacks in accessible large joints. 1, 3
• Corticosteroids are the safest first-line option in patients with renal impairment, cardiovascular disease, or gastrointestinal risk factors. 3

Combination Therapy for Severe Attacks

For severe polyarticular gout with pain >6/10 or involvement of multiple large joints, combine two anti-inflammatory agents from different classes (e.g., corticosteroid + colchicine or corticosteroid + NSAID). 1

Critical Management Principles

• Continue all established urate-lowering therapy (allopurinol, febuxostat) without interruption during acute flares. 2, 1 Stopping ULT prolongs the attack and destabilizes urate control. 1
• Do not initiate urate-lowering therapy during an acute flare in most patients; defer until after complete resolution. 1
• Maintain anti-inflammatory therapy at full therapeutic dose for 5-14 days until symptoms fully resolve. 1
• Inadequate response is defined as <20% pain improvement within 24 hours or <50% improvement at ≥24 hours. 1, 3

---

Long-Term Urate-Lowering Therapy (ULT)

Indications for Starting ULT

Absolute indications include: any tophus on exam or imaging, frequent attacks (≥2 per year), history of urolithiasis, chronic kidney disease, or chronic gouty arthritis. 1

Target Serum Uric Acid Level

The minimum target is serum uric acid <6 mg/dL for all patients, with some requiring <5 mg/dL to resolve tophi and improve symptoms. 1 Although lower urate levels reduce recurrent attacks, treatment to a specific target level has not been tested in placebo-controlled trials. 2

Allopurinol: First-Line ULT

Starting Dose

• Start allopurinol 100 mg/day for most patients. 1
• In chronic kidney disease stage 4 or worse (eGFR <30 mL/min), start at 50 mg/day. 1

Dose Titration

• Titrate every 2-5 weeks by 100 mg increments until serum uric acid <6 mg/dL. 1
• Maximum dose is 800 mg/day. 1, 4
• Patients with severely impaired renal function may require only 100 mg/day or 300 mg twice weekly to maintain adequate xanthine oxidase inhibition. 4

Mandatory Prophylaxis When Starting ULT

All patients starting urate-lowering therapy must receive concurrent prophylactic anti-inflammatory medication to prevent acute gout flares. 1 Acute attacks are commonly triggered during the first months of ULT due to rapid urate mobilization. 2, 4

Prophylaxis Options

• Low-dose colchicine 0.5-0.6 mg once or twice daily is first-line prophylaxis. 2, 1
• Low-dose NSAID with gastric protection if indicated. 2, 1
• Low-dose prednisone (<10 mg/day) is second-line if colchicine and NSAIDs are contraindicated. 1, 3

Duration of Prophylaxis

• Continue prophylaxis for a minimum of 8 weeks. 2, 1
• Extend prophylaxis until the patient is attack-free and serum uric acid target is achieved, typically 3-6 months. 1 Longer prophylaxis is needed for patients with greater crystal loads or tophi. 2

Dose Adjustments in Renal Impairment

Colchicine Dose Reduction

• Mild-to-moderate renal impairment (CrCl 30-80 mL/min): No dose adjustment required for prophylaxis, but monitor closely. 5
• Severe impairment (CrCl <30 mL/min): Start prophylaxis at 0.3 mg/day; increase cautiously with close monitoring. 5
• Dialysis patients: Start at 0.3 mg twice weekly for prophylaxis. 5
• For acute gout treatment in dialysis patients, use a single 0.6 mg dose; do not repeat more than once every two weeks. 5

Allopurinol in Renal Impairment

• Patients with decreased renal function require lower allopurinol doses and should be observed closely during early therapy. 4
• In severely impaired renal function, the half-life of oxipurinol is greatly prolonged. 4

---

Common Pitfalls to Avoid

• Stopping urate-lowering therapy during acute attacks undermines long-term control and prolongs symptoms. 1
• Starting ULT without prophylaxis virtually guarantees flares and treatment abandonment. 1
• Inadequate allopurinol dose titration leaves patients above target uric acid levels. 1
• Discontinuing ULT after symptoms resolve leads to recurrent attacks and progressive joint damage. 1
• Using high-dose colchicine (hourly dosing) for acute attacks provides no additional efficacy but markedly increases gastrointestinal toxicity. 1
• Delaying treatment beyond 24 hours significantly reduces effectiveness of all anti-inflammatory agents. 1

---

Special Populations

Renal Impairment

• Corticosteroids are the safest first-line option for acute gout in severe renal impairment (eGFR <30 mL/min). 3 NSAIDs can precipitate acute kidney injury, and colchicine toxicity is markedly increased. 3, 5
• Prednisone 30-35 mg daily for 5 days requires no dose adjustment in renal impairment. 3

Hepatic Impairment

• Corticosteroids are preferred for acute gout when hepatic impairment is present because they are not dependent on hepatic metabolism. 1
• NSAIDs are contraindicated due to hepatotoxicity risk. 1
• Colchicine is metabolized by the liver and toxicity is markedly increased in hepatic dysfunction. 1

Drug Interactions with Colchicine

• Colchicine dose must be reduced by 50-75% when used with strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, atazanavir). 5
• Treatment of acute gout with colchicine is not recommended in patients receiving prophylactic colchicine and CYP3A4 inhibitors. 5