Acute Gout: Topic of the Day

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From the Rheumatology Guidelines 2012:

Patient education on diet, lifestyle, treatment objectives, and management of comorbidities is a recommended core therapeutic measure in gout. Foods to avoid are organ meats, foods containing high-fructose corn syrup, and excessive alcohol use; foods to limit are large portions or concentrations of meat and seafood, naturally sweet fruit juices, sugar, desserts, and salt; and foods that are encouraged include low-fat or nonfat dairy and vegetables.  Of course also maintaining a healthy weight, exercising and smoking cessation are important in the management of gout.

Urate-lowering therapy (ULT) should be considered in patients with 1 or more tophi, ≥2 attacks per year, chronic kidney disease (CKD; stage 2 or worse) and urolithiasis:

First line: Xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat is recommended as the first-line pharmacologic urate-lowering therapy (ULT) approach in gout).

Alternative: probenacid

Serum urate level should be lowered sufficiently to durably improve signs and symptoms of gout, with the target 6 mg/dl at a minimum, and often 5 mg/dl.

 

Allopurinol:

Starting allopurinol dose should not exceed 100 mg/day, and patients with CKD of stage 4 or higher should be started at 50 mg/day. Dosages should be titrated up every 2-5 weeks to achieve target serum uric acid and can go above 300 mg/day as long as the patient is educated and monitored for adverse events. 

  • Caveat: Prior to initiation of allopurinol, rapid polymerase chain reaction– based HLA–B*5801 screening should be considered as a risk management component in subpopulations where both the HLA– B*5801 allele frequency is elevated and the HLA– B*5801–positive subjects have a very high hazard ratio (“high risk”) for severe allopurinol hypersensitivity reaction (e.g., Koreans with stage 3 or worse CKD and all those of Han Chinese and Thai descent).

Combination oral ULT with 1 XOI agent and 1 uricosuric agent is appropriate when the serum urate target has not been met by appropriate dosing of an XOI.

Pegloticase is appropriate for patients with severe gout disease burden and refractoriness to, or intolerance of, appropriately dosed oral ULT options.