Management of gout

The two goals, and the four phases they map onto. The goal of treatment is to terminate the acute attack and then prevent future attacks by considering underlying causes — for example, considering hypouricaemic therapy. Gout progresses through asymptomatic hyperuricaemia → acute intermittent gout → the intercritical period → chronic tophaceous gout, in which tophi, which are subcutaneous urate deposits on extensor surfaces, develop in the later phases and are sometimes confused with rheumatoid arthritis and its nodules. Management differs at each phase, and the fundamental principle is that the acute attack is treated with anti-inflammatories and the disease is cured only by lowering urate.

Acute attack — summarised. The acute phase should be managed using short-term NSAIDs, colchicine, corticotrophin or corticosteroids, with the choice based on patient comorbidities such as renal function and gastrointestinal disease. In older adults, low-dose colchicine or corticosteroids (intra-articular for a single joint, oral for polyarticular disease) are usually safer than NSAIDs. Colchicine can be used for acute management as well as for prophylaxis. Never stop existing urate-lowering therapy during a flare.

Who needs urate-lowering therapy, and which drug. Indications: two or more flares per year, any tophus, radiographic erosion, chronic kidney disease stage 3 or worse, urolithiasis, or a very high serum urate. Allopurinol is the first-line urate-lowering therapy, and due to the renal changes associated with ageing, allopurinol is recommended over probenecid in older individuals — probenecid is a uricosuric and loses efficacy as GFR falls, besides risking stones. Febuxostat, the other xanthine oxidase inhibitor, is the alternative in allopurinol intolerance, but is limited by the increased cardiovascular and all-cause mortality seen in studies (the CARES trial), so it is second-line. An xanthine oxidase inhibitor is recommended over probenecid in CKD stage 3 or worse.

How to prescribe it — start low, titrate to target, cover with prophylaxis. Start at a low dose with subsequent titration to target rather than starting high — allopurinol under 100 mg/day, and lower still in CKD (50 mg); febuxostat under 40 mg/day. Adjust the dose upward every 2–5 weeks according to the uric acid level. ACR guidance advises that the allopurinol dose can be raised above 300 mg/day even in patients with renal impairment, provided there is adequate monitoring — the older practice of capping the dose by creatinine clearance left most patients under-treated. Initiate concomitant anti-inflammatory prophylaxis — colchicine, an NSAID, or low-dose prednisolone — over no prophylaxis, and continue it for 3–6 months rather than less than 3 months, since urate-lowering drugs precipitate attacks by mobilising crystal deposits.

Treat-to-target, and when to stop prophylaxis. Titrate to a serum urate below 6 mg/dL — this decreases flares and increases treatment adherence — and to below 5 mg/dL in tophaceous gout, because tophi dissolve only below the saturation point. Once the target has been achieved and maintained for 6 months, discontinue colchicine prophylaxis, unless the patient has one or more tophi on clinical examination. Urate-lowering therapy itself is continued indefinitely — continuing it is preferred over stopping even in patients who are flare-free and tophus-free. Asymptomatic hyperuricaemia should not, as a general rule, be treated.

Non-pharmacological management and the geriatric considerations. Address alcohol (especially beer and spirits), red and organ meat, shellfish, and fructose-sweetened drinks; encourage weight loss, hydration, low-fat dairy and vitamin C. Adjust contributing medications such as diuretics — substituting a thiazide, or switching to losartan (mildly uricosuric) or a calcium-channel blocker for hypertension, is one of the most effective single interventions in an older patient. Geriatric-specific issues: gout in older adults is more often polyarticular, involves the upper limbs and small hand joints, is more frequent in women after the menopause, is strongly diuretic-associated, and presents with tophi earlier — sometimes on osteoarthritic Heberden's and Bouchard's nodes, where it is easily mistaken for nodal osteoarthritis or rheumatoid arthritis. Monitor renal function, review the whole drug list, and remember that carpal tunnel syndrome is common in older adults and can be confused with gout, rheumatoid arthritis or pseudogout. Drug Class / mechanism Dose in the older Cautions adult Allopurinol Xanthine oxidase Start 50–100 mg daily; HLA-B*5801 hypersensitivity (test in Southeast inhibitor titrate every 2–5 weeks; Asian and African descent); rash, DRESS; may exceed 300 mg interacts with azathioprine Febuxostat Xanthine oxidase Start <40 mg daily Second-line — cardiovascular and all-cause inhibitor mortality signal (CARES); hepatotoxicity Probenecid Uricosuric 500 mg once or twice Avoid in the elderly and in CKD stage >3; daily, titrated urolithiasis Colchicine Anti-inflammatory Acute: 1.2 mg then 0.6 Reduce in renal and hepatic impairment; (tubulin) mg at 1 h. Prophylaxis: myopathy and marrow suppression with 0.5–0.6 mg once or statins, clarithromycin, verapamil, twice daily diltiazem, ciclosporin Corticosteroid Anti-inflammatory Intra-articular, or Hyperglycaemia, delirium, fluid retention, prednisolone 30–35 mg infection risk for 5 days Pegloticase Recombinant uricase Specialist use, IV Refractory tophaceous gout only; infusion reactions, anaphylaxis; contraindicated in G6PD deficiency LATEST UPDATE (2023–PRESENT) — 1 POINT

The two current shifts are treat-to-target with early initiation, and the head-to-head vindication of allopurinol. The ACR guideline's central change was the emphasis on a "treat-to-target" strategy — treating as aggressively as needed to keep serum urate below 6 mg/dL, supported by trials published since the 2012 guideline. Alongside this, urate-lowering therapy may now be started during a flare under anti-inflammatory cover, capitalising on the moment the patient is most motivated. On drug choice, the STOP-Gout trial (NEJM Evidence 2022) found allopurinol non-inferior to febuxostat when both were properly dose-escalated to target, including in patients with chronic kidney disease — confirming that most "allopurinol failure" is in fact under-dosing rather than drug failure. The FAST trial (Lancet 2020) did not replicate the CARES cardiovascular mortality signal for febuxostat, so the position is now that febuxostat is a reasonable alternative but allopurinol, correctly titrated, remains first choice. Finally, gout is increasingly framed as a cardiovascular risk marker, with guideline-concordant therapy improving endothelial function and reducing intercritical inflammation — a useful closing line in a geriatrics answer.