SECTION 1

BONE AND JOINT DISORDERS

Edited by Terry L. Schwinghammer

CHAPTER

Gout
1 Gout and Hyperuricemia

PATHOPHYSIOLOGY

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SECTION 1 | Bone and Joint Disorders

CLINICAL PRESENTATION

DIAGNOSIS

TREATMENT

ACUTE GOUTY ARTHRITIS (FIG. 1–1)

Nonpharmacologic Therapy

Pharmacologic Therapy

NSAIDS

Table 1–1

CORTICOSTEROIDS

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 Mild/Moderate Severe
Pain intensity

Initiate Monotherapy:a Initiate Combination Therapy:c

a +
a,e + Oral corticosteroid
a + Intra-articular corticosteroid
+ Intra-articular corticosteroid
+ Intra-articular corticosteroid
Successful Inadequate responsed
Treatment outcome Treatment Outcome

Switch to Alternative Monotherapyc

ry modifications to
prevent hyperuricemiab

Gout and Hyperuricemia

b Successful
Inadequate
b
responsed

Off-Label Therapies in Development

urate-lowering therapy)c
a Evidence Grade Level A: Supported by multiple randomized clinical trials or meta-analyses
b Evidence Grade Level B: Derived from a single randomized trial, or nonrandomized studies

|
c
Evidence Grade Level C: Consensus opinion of experts, case studies, or standard-of-care

CHAPTER 1
d ‘Inadequate Response’ is defined as <20% improvement in pain score within 24 hours or <50% at ≥ 24 hours
e
Colchicine is recommended only if started within 36 hours of symptom onset

FIGURE 1–1. Algorithm for management of an acute gout attack.

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SECTION 1 | Bone and Joint Disorders

TABLE 1–1 Dosage Regimens of Oral Nonsteroidal Anti-inflammatory Drugs for

Treatment of Acute Gout
Generic Name Initial Dose
Etodolac 300 mg twice daily
Fenoprofen 400 mg three times daily
Ibuprofen 400 mg three times daily
Indomethacin 50 mg three times daily
Ketoprofen 75 mg three times daily or 50 mg
four times daily
Naproxen 750 mg followed by 250 mg every
8 h until the attack has subsided
Piroxicam 20 mg once daily or 10 mg twice
daily
Sulindac 150 mg twice daily
Celecoxib 800 mg followed by 400 mg on
day 1, then 400 mg twice daily
for 1 week
Usual Range
300–500 mg twice daily
400–600 mg three to four times
daily
400–800 mg three to four times
daily
50 mg three times daily initially
until pain is tolerable then rapidly
reduce to complete cessation
50–75 mg three to four times daily
—
—
150–200 mg twice daily for 7–10
days
—

Prednisone prednisolone

Methylprednisolone dose pack

Triamcinolone acetonide

Methylprednisolone

Adrenocorticotropic hormone (ACTH)

COLCHICINE
Colchicine

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 Gout and Hyperuricemia | CHAPTER 1

Colcrys

HYPERURICEMIA IN GOUT

Nonpharmacologic Therapy

Pharmacologic Therapy (Fig. 1–2)

5
 No Yes
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SECTION 1 | Bone and Joint Disorders

a
Does patient have an indication for Urate-Lowering Therapy (ULT)?

d
Nonpharmacologic Urate-Lowering Strategies ULT Initiation Antiinflammatory Gout Prophylaxis During ULT Initiation
Dietary Modifications First-Line First-Line
b b
) e
d
ry consumption Allopurinol
Eliminate Urate-Elevating Medications if Unnecessary Febuxostat Second-Line
d
Alternative
c

Titrate ULT to No Achieved Yes Evidence of gout activity

maximum dose urate target? while taking ULT?

No
Yes Continue prophylactic therapy
Achieved
urate target? Yes
No Yes
No Tophus present?

add uricosuric therapy Discontinue

Continue all measures needed to maintain serum Discontinue prophylactic
d prophylactic
urate <6 mg/dL indefinitely therapy after the greater of:
b therapy after
1) 6 months
6 months
following
2) 3 months following
achievement of
Achieved Yes achievement of urate d
c urate target
Urate Target? target
No

Switch to
pegloticase
aIndications for ULT include: (1) presence of tophus, (2) ≥2 gout attacks per year, (3) CKD stage 2 or worse, or (4) past urolithiasis
bEvidence Grade Level A: Supported by multiple randomized clinical trials or meta-analyses
cEvidence Grade Level B: Derived from a single randomized trial, or nonrandomized studies
dEvidence Grade Level C: Consensus opinion of experts, case studies, or standard-of-care

FIGURE 1–2. Algorithm for management of hyperuricemia in gout.

 Gout and Hyperuricemia | CHAPTER 1

XANTHINE OXIDASE INHIBITORS

Allopurinol

Febuxostat

URICOSURICS
Probenecid

PEGLOTICASE
Pegloticase

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SECTION 1 | Bone and Joint Disorders

ANTIIFLAMMATORY PROPHYLAXIS DURING INITIATION

OF URATE-LOWERING THERAPY

EVALUATION OF THERAPEUTIC OUTCOMES

See Chapter 74, Gout and Hyperuricemia, authored by Michelle A. Fravel, Michael E.
Ernst, and Elizabeth C. Clark, for a more detailed discussion of this topic.
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