What is the first-line management for acute gout and when to check serum uric acid levels?

From the Guidelines

First-line management of acute gout involves prompt initiation of anti-inflammatory therapy, with colchicine, NSAIDs, or corticosteroids being the preferred options, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. The choice of drug should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved.

• Colchicine should be given at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, as stated in the 2016 updated EULAR recommendations 1.
• NSAIDs can be used, but should be avoided in patients with severe renal impairment, and should be given with proton pump inhibitors if appropriate 1.
• Oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) can be used as an alternative 1. Uric acid levels should not be measured during an acute attack, as they may be falsely normal or even low during flares 1.
• The appropriate time to check uric acid is when initiating urate-lowering therapy (ULT), with a target level of <6 mg/dL (360 mmol/L) 1.
• In patients with severe gout, a lower SUA target (<5 mg/dL; 300 mmol/L) is recommended to facilitate faster dissolution of crystals 1. It is essential to educate patients on lifestyle modifications, including weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, to reduce the risk of gout attacks and improve overall health 1.

From the FDA Drug Label

The recommended dosage of Colchicine Tablets, USP for prophylaxis of gout flares for adults and adolescents older than 16 years of age is 0.6 mg once or twice daily. The maximum recommended dose for prophylaxis of gout flares is 1.2 mg/day. An increase in gout flares may occur after initiation of uric acid-lowering therapy, including pegloticase, febuxostat and allopurinol, due to changing serum uric acid levels resulting in mobilization of urate from tissue deposits. Colchicine Tablets, USP are recommended upon initiation of gout flare prophylaxis with uric acid-lowering therapy Prophylactic therapy may be beneficial for at least the first six months of uric acid-lowering therapy.

First line management of acute gout:

• The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later.
• Higher doses have not been found to be more effective.
• The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period.

When to check uric acid:

• Uric acid levels should be monitored after initiation of uric acid-lowering therapy, as an increase in gout flares may occur due to changing serum uric acid levels.
• Prophylactic therapy with Colchicine Tablets, USP may be beneficial for at least the first six months of uric acid-lowering therapy 2.

From the Research

Acute Gout First Line Management

• The first line management for acute gout includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and oral or intramuscular corticosteroids 3, 4, 5, 6, 7.
• NSAIDs are commonly used to treat acute gout, with moderate-certainty evidence showing they are effective in reducing pain and inflammation 5.
• Colchicine is also effective in treating acute gout, with low-quality evidence suggesting it may improve treatment outcomes compared to placebo, and similar benefits to NSAIDs 6.
• Corticosteroids, including systemic and intraarticular glucocorticoids, are also effective in treating acute gout, with moderate quality evidence showing they are as effective as NSAIDs but safer 7.

When to Check Uric Acid

• Uric acid levels should be checked after the resolution of the acute attack, as part of the long-term management of gout 4.
• The target uric acid value is <6 mg/dL, and treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course 4.
• Regular laboratory follow-up is necessary to monitor uric acid levels and adjust treatment as needed 4.