Key facts about gout medications
- Acute gout therapies focus on quickly reducing inflammation, while urate-lowering medicines prevent future flares.
- Colchicine, NSAIDs, and corticosteroids remain first-line options for flares when started within 12 to 36 hours.
- Allopurinol and febuxostat are the most commonly used long-term agents; doses must be titrated to uric acid targets.
Gout management hinges on selecting the right medication at the right time. Acute flare therapies tackle pain and swelling, whereas long-term urate-lowering treatments reduce the serum uric acid level that drives crystal formation. Understanding how each medicine works, the ideal dosing window, and key monitoring steps will help you work with your clinician to prevent joint damage.
Medication categories at a glance
| Category | Examples | Primary goal | Typical duration |
|---|---|---|---|
| Anti-inflammatory agents for flares | Colchicine, naproxen, indomethacin, etoricoxib | Reduce pain and swelling during acute attacks | 1 to 7 days depending on response |
| Systemic corticosteroids | Prednisolone, methylprednisolone dose pack | Alternative when NSAIDs/colchicine are unsuitable | 3 to 10 days with taper |
| Urate-lowering therapy (ULT) | Allopurinol, febuxostat | Lower serum uric acid and prevent future flares | Long term, reassessed every 6 to 12 months |
| Uricosurics | Probenecid, benzbromarone | Increase renal uric acid excretion | Long term for selected patients |
| Biologic agents | Pegloticase | Rapid uric acid reduction in refractory gout | Intermittent infusions under specialist care |
Managing an acute flare
- Colchicine: Start with 1 mg, followed by 0.5 mg one hour later (maximum 1.5 mg/day). Reduce the dose in renal impairment or when taking CYP3A4/P-gp inhibitors.
- NSAIDs: Common regimens include naproxen 500 mg twice daily or indomethacin 50 mg three times daily. Continue for 48 hours after symptom resolution, provided renal and gastrointestinal profiles allow.
- Corticosteroids: Prednisolone 30 to 35 mg once daily for 3 to 5 days, tapering as symptoms improve. Intra-articular injections are useful when only one joint is affected.
- Adjuncts: Ice packs, elevation, and short-term rest support medication efficacy.
Long-term urate-lowering therapy
| Medicine | Starting dose | Titration strategy | Key monitoring |
|---|---|---|---|
| Allopurinol | 50 to 100 mg once daily | Increase by 50 to 100 mg every 2 to 4 weeks until serum uric acid < 360 μmol/L (or < 300 μmol/L for tophaceous gout) | Renal function, liver enzymes, rash or hypersensitivity |
| Febuxostat | 40 mg once daily | Increase to 80 mg after 2 to 4 weeks if target uric acid is unmet | Liver enzymes, cardiovascular history review |
| Probenecid | 250 mg twice daily | Increase to 500 to 1000 mg twice daily as tolerated | Renal stone risk, uric acid, hydration status |
| Pegloticase | 8 mg IV every 2 weeks | Used for refractory cases under specialist supervision | Infusion reactions, uric acid every infusion, G6PD status prior to therapy |
Prophylaxis during ULT initiation
Initiating ULT can precipitate flares as urate stores mobilise. Prophylaxis helps maintain adherence.
- Colchicine 0.5 mg once or twice daily for the first 3 to 6 months is widely recommended.
- Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) may be used if colchicine is not tolerated and renal function permits.
- Low-dose prednisolone (5 to 10 mg daily) is an option for individuals with renal contraindications to both colchicine and NSAIDs.
Monitoring schedule
| Time point | Assessments | Purpose |
|---|---|---|
| 2 to 4 weeks after starting or changing ULT | Serum uric acid, renal function, flare frequency | Adjust dose and reinforce prophylaxis adherence |
| Every 3 months during titration | Uric acid, liver enzymes (if on allopurinol/febuxostat), medication tolerance | Ensure targets are met and adverse effects identified early |
| Every 6 to 12 months once stable | Uric acid, kidney function, cardiovascular risk factors | Maintain remission and reassess need for therapy adjustments |
Safety considerations
- Allopurinol hypersensitivity syndrome: Rare but serious; risk increases with renal impairment, thiazide use, or HLA-B*5801 allele (common in certain Asian populations).
- Colchicine toxicity: Presents with gastrointestinal upset, myopathy, or bone marrow suppression; avoid combining with strong CYP3A4 or P-glycoprotein inhibitors.
- NSAID risks: Watch for gastrointestinal bleeding, renal insufficiency, and cardiovascular effects in high-risk individuals.
- Corticosteroids: Can worsen glucose control, blood pressure, and mood; taper cautiously to avoid rebound flares.
Drug interactions to know
- Allopurinol + azathioprine/6-mercaptopurine: Dramatically raises levels; dose adjustments or alternative immunosuppression is required.
- Colchicine + clarithromycin, cyclosporine, or certain antifungals: Increases toxicity risk; seek medical advice before combining.
- NSAIDs + anticoagulants: Heightens bleeding risk; gastroprotective strategies may be needed.
- Thiazide diuretics: Can elevate uric acid and predispose to allopurinol hypersensitivity.
Special populations
| Population | Considerations | Medication tips |
|---|---|---|
| Chronic kidney disease | Reduced drug clearance and higher risk of toxicity | Start allopurinol at 50 mg daily, avoid high-dose NSAIDs, adjust colchicine interval |
| Pregnancy | Most urate-lowering therapies are not well studied | Acute flares may be treated with steroids; defer ULT initiation unless benefits outweigh risks |
| Older adults | Polypharmacy and comorbidities common | Review drug interactions carefully and use lowest effective doses |
| Patients with cardiovascular disease | Febuxostat carries warnings for certain high-risk groups | Consider allopurinol first line; monitor for edema and blood pressure changes during steroid use |
Self-management checklist
- Track serum uric acid results and flare frequency in a journal or app.
- Note any side effects immediately and share them at follow-up visits.
- Maintain hydration and balanced nutrition to support uric acid control.
- Store medications according to package insert guidance and check expiry dates.
Frequently asked questions
How long should I continue urate-lowering therapy?
ULT is usually continued indefinitely once recurrent gout has been diagnosed, provided it remains well tolerated and serum uric acid stays below target. Stopping therapy often leads to flare recurrence.
Can I start allopurinol during an acute flare?
Guidelines now allow continuation or even initiation of ULT during a flare if appropriate anti-inflammatory cover is provided. The key is to maintain consistent dosing once started.
Do vitamin C or cherry supplements replace medication?
They may offer mild uric acid lowering but should be considered adjuncts only. Evidence is limited compared with prescription options.
What if I cannot tolerate colchicine?
NSAIDs, corticosteroids, or IL-1 inhibitors (for severe refractory cases) can be considered. Discuss alternatives with your rheumatology or primary care team.
