Acute Gout
First-line pharmacologic treatment options for an acute gout flare (3).
Colchicine, NSAIDs, or glucocorticoids.
Primary mechanism of colchicine in gout.
Inhibits microtubule polymerization → ↓ neutrophil activation.
Common NSAID used for acute gout flares.
Indomethacin (or naproxen).
Target serum urate level during chronic gout management.
< 6 mg/dL.
Alcohol most strongly associated with gout flares.
Beer (and spirits).
When should acute gout therapy ideally be started after symptom onset?
Within 24 hours.
Most common adverse effect of colchicine.
GI upset (diarrhea, nausea).
Typical duration of NSAID therapy for acute gout.
3–5 days or until symptoms resolve.
First-line urate-lowering therapy for most patients.
Allopurinol.
Dietary items patients should limit to reduce gout flares.
Red meat, shellfish, high-fructose corn syrup.
This type of gout flare may require combination therapy.
Severe or polyarticular gout.
This toxicity risk increases when colchicine is combined with statins.
Myopathy / rhabdomyolysis.
Which patients should avoid NSAIDs for gout?
Those with CKD, HF, or peptic ulcer disease.
Which ULT requires HLA-B*5801 testing in certain populations?
Allopurinol.
Pearl:
Black and Southeast Asian patients for DRESS and SJS
Antihypertensive medication preferred in gout patients.
Losartan.
A patient with gout and CKD presents with an acute flare. Which common option should be avoided?
NSAIDs.
Colchicine is contraindicated in patients with this condition.
Severe CKD.
Preferred alternative when NSAIDs and colchicine are contraindicated.
Glucocorticoids (e.g., prednisone).
ULT associated with increased cardiovascular mortality.
Febuxostat.
Diuretic that increases uric acid levels and should be avoided.
Hydrochlorothiazide.
True or False: Urate-lowering therapy should be started during an acute gout flare.
False.
Pearl:
Start ULT after flare resolves, with prophylaxis on board.
Which enzyme system inhibitors increase colchicine toxicity?
CYP3A4 inhibitors.
Acceptable combination therapy for severe gout flare.
NSAID + colchicine or glucocorticoid + colchicine.
IV-only urate-lowering agent contraindicated in G6PD deficiency.
Pegloticase.
Non-dietary comorbidity that should be identified and treated to improve gout control.
Sleep apnea.