From the Guidelines
For a 42-year-old patient experiencing their first presumptive gout attack with a uric acid level of 6.8 mg/dL, I recommend immediate treatment with an anti-inflammatory medication to manage the acute attack, such as colchicine or an NSAID, as the first-line treatment according to the 2020 American College of Rheumatology guideline for the management of gout 1.
Management of Acute Gout Attack
The patient should be started on either colchicine 1.2 mg initially, followed by 0.6 mg one hour later, then 0.6 mg once or twice daily until symptoms resolve; or an NSAID such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily for 3-5 days.
- For patients with contraindications to these medications, a short course of oral prednisone at 30-40 mg daily for 3-5 days with a taper over 7-10 days is appropriate.
- During the acute attack, the affected joint should be rested, elevated, and ice can be applied intermittently.
- Adequate hydration is important, as noted in the 2017 American College of Physicians guideline for the management of acute and recurrent gout 2.
Long-term Management
After resolution of the acute attack, the patient should be evaluated for long-term management, which may include lifestyle modifications such as:
- Weight loss if overweight
- Limiting alcohol (especially beer) and purine-rich foods
- Possibly urate-lowering therapy if they have risk factors for recurrent attacks, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 3. However, urate-lowering therapy should not be initiated during an acute attack as it may worsen symptoms, and the decision to start urate-lowering therapy should be based on the presence of risk factors for recurrent attacks, such as frequent flares, tophi, or renal stones, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
From the Research
Management of First Presumptive Gout Attack
- The patient's uric acid level is 6.8, which is slightly elevated, but the primary goal is to manage the acute gout attack.
- According to 4, 5, 6, 7, 8, the first-line treatment options for acute gout include non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids.
- These medications are equally efficacious, and the choice of treatment should be guided by the patient's comorbidities.
Urate-Lowering Therapy
- Urate-lowering therapy is not typically initiated during an acute gout attack, but rather after the attack has resolved.
- According to 4, 5, 6, 7, 8, allopurinol and febuxostat are commonly used urate-lowering therapies, with a target serum uric acid level of <6 mg/dL.
- However, the patient's renal function and baseline serum uric acid concentration should guide the starting dose and maintenance dose of allopurinol.
Treatment Considerations
- The patient's age and comorbidities should be taken into consideration when selecting a treatment option.
- According to 5, 7, comprehensive patient education and counseling, as well as regular laboratory follow-up, are important components of gout management.
- Lifestyle modifications, such as dietary changes and weight loss, may also be beneficial in preventing future gout attacks.