Drug regimens for chronic gout

There is strong consensus that allopurinol should be used as first-line urate-lowering therapy. As a two-drug regimen, initially, for urate-lowering therapy and flare prophylaxis in chronic gout, use:

allopurinol 50 mg orally, daily; then increase the daily dose by 50 mg every 2 weeks or by 100 mg every 4 weeks up to a maximum daily dose of 900 mg to achieve the target serum uric acid concentration allopurinol allopurinol allopurinol

PLUS for flare prophylaxis

colchicine 500 micrograms orally, daily for at least 6 months. Reduce dosage in kidney impairment or in people who experience diarrhoea. colchicine colchicine colchicine

If a colchicine alternative is needed for flare prophylaxis, consider an NSAID or oral corticosteroids—see Prevention of gout flares when starting or changing urate-lowering therapy for drug choice. The duration of therapy should be individualised because long-term use can be associated with unacceptable adverse effects. Limit treatment to the lowest dose and shortest duration of treatment. For flare prophylaxis in chronic gout, use:

1celecoxib 100 to 200 mg orally, daily in 1 or 2 divided doses, until symptoms subside celecoxib celecoxib celecoxib

OR

1etoricoxib 30 to 60 mg orally, daily until symptoms subside etoricoxib etoricoxib etoricoxib

OR

1ibuprofen immediate-release 200 to 400 mg orally, 3 or 4 times daily until symptoms subside ibuprofen ibuprofen ibuprofen

OR

1indometacin 25 to 50 mg orally, 2 to 4 times daily until symptoms subside indometacin indometacin indometacin

OR

1ketoprofen modified-release 200 mg orally, daily until symptoms subside ketoprofen ketoprofen ketoprofen

OR

1meloxicam 7.5 to 15 mg orally, daily until symptoms subside meloxicam meloxicam meloxicam

OR

1naproxen immediate-release 250 to 500 mg orally, twice daily until symptoms subside naproxen naproxen naproxen

OR

1naproxen modified-release 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen

OR

1piroxicam 10 to 20 mg orally, daily until symptoms subside piroxicam piroxicam piroxicam

OR

2diclofenac 25 to 50 mg orally, 2 or 3 times daily until symptoms subside diclofenac diclofenac diclofenac

OR

2prednisolone (or prednisone) 5 mg orally, daily until symptoms subside. prednis ol one prednis(ol)one prednis(ol)one

If the target serum uric acid concentration is not achieved with allopurinol, check adherence before altering therapy because allopurinol therapy is rarely ineffective.

Note: Allopurinol therapy is rarely ineffective; check adherence before altering therapy.

If the target serum uric acid concentration cannot be achieved despite adherence, probenecid (a weak uricosuric) may be added to allopurinol. For urate lowering therapy (in combination with allopurinol) for chronic gout, use:

probenecid 250 mg orally, twice daily for 1 week, then increase to 500 mg twice daily; then increase the daily dose by 500 mg every 4 weeks to achieve the target serum uric acid concentration. Maximum dose 2 g daily, in divided doses. probenecid probenecid probenecid

If allopurinol is contraindicated or not tolerated, replace allopurinol in the two drug regimen above with either:

1febuxostat 40 mg orally, daily for 2 to 4 weeks; then increase the daily dose by 40 mg every 2 to 4 weeks to achieve the target serum uric acid concentration. Maximum daily dose 120 mg1 febuxostat febuxostat febuxostat

OR

2probenecid 250 mg orally, twice daily for 1 week, then increase to 500 mg twice daily; then increase the daily dose by 500 mg every 4 weeks to achieve the target serum uric acid concentration. Maximum dose 2 g daily, in divided doses. probenecid probenecid probenecid

1 The maximum daily dose of febuxostat in the Australian approved product information is 80 mg; however, daily doses of up to 120 mg are approved in other countries.Return