[Therapy of gout in 2024]

The treatment of gout includes anti-inflammatory therapy and prophylaxis of flare-ups on the one hand and measures for long-term uric acid reduction on the other. Acute arthritis urica is best relieved by intra-articular steroids; systemic steroids, NSAIDs and, in exceptional cases, colchicine are also suitable. For the prophylaxis of relapses, long-term use of colchicine, NSAIDs or low-dose steroids is an option. However, the main pillar of gout therapy is pharmacological reduction of uric acid. The xanthine oxidase inhibitors allopurinol and febuxostat are best suited. The goal is a serum uric acid below 360 µmol/l ("treat to target"). The «start low, go slow» strategy reduces the risk of relapses and, in the case of allopurinol, the occurrence of hypersensitivity syndrome. Allopurinol is started at a maximum of 100 mg/d (less in renal insufficiency), followed by a slow upward titration to the required maintenance dose, which may largely exceed 300 mg/d (also in renal insufficiency). Febuxostat is started at a maximum of 40 mg/d and also titrated upwards. The most common cause of insufficient uric acid reduction is unreliable medication intake. In the management of gout, its comorbidities should also be sought and addressed.