Management of Gout

Core Management Principles

The European League Against Rheumatism (EULAR) recommends patient education, treat-to-target urate lowering, and early aggressive treatment of acute flares as the foundation for gout management 1, 2
Patient education increases adherence to urate-lowering therapy (ULT) to 92% at 12 months, making this the single most important intervention 1, 5
Patients should be educated to self-medicate acute flares at first warning symptoms 1, 3
Lifestyle modifications, including weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, are essential for reducing serum uric acid (SUA) levels and preventing attacks 1, 2, 3
Comorbidity screening for cardiovascular risk factors, including renal impairment, coronary heart disease, and hypertension, is mandatory 1, 4, 6

The EULAR recommends treating acute flares as early as possible with colchicine, NSAIDs, or corticosteroids 1, 3, 6
Colchicine should be started with a 1 mg loading dose, followed by 0.5 mg one hour later, and then 0.5 mg daily 1, 3
NSAIDs, including non-selective NSAIDs and COX-2 inhibitors, can be used with proton pump inhibitors if appropriate 1, 3
Corticosteroids, including oral prednisolone and intra-articular injections, can be used for acute flares 1, 3, 6

The EULAR recommends considering ULT for all patients with gout, with a target serum uric acid (SUA) level of <6 mg/dL (360 μmol/L) lifelong 1, 2, 4
Allopurinol is the first-line ULT, started at 100 mg daily and increased by 100 mg every 2-4 weeks until the SUA target is achieved 1, 2, 9
Febuxostat and uricosurics, including benzbromarone and probenecid, are alternative ULT options 1, 2, 8, 9
Pegloticase is a last resort for crystal-proven severe debilitating chronic tophaceous gout when all other drugs have failed 1, 2

Prophylaxis is mandatory for the first 6 months of ULT, with colchicine 0.5-1 mg daily as the first choice 1, 3, 4
Low-dose NSAIDs can be used as an alternative if colchicine is contraindicated or not tolerated 1, 3

Diuretic-associated gout should be managed by substituting the diuretic if possible, and considering losartan or calcium channel blockers for hypertension 1, 2
Tophaceous gout should be treated medically by achieving sustained SUA reduction, preferably <5 mg/dL (300 μmol/L) 8, 9
Asymptomatic hyperuricemia should not be treated with ULT 9