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 | | Drug Therapy | |
- Recognize that optimal management of acute gout requires control of inflammation as well as pain relief.
- Recognize that effective management of recurrent gout attacks or chronic gout (monosodium urate deposition) requires drug therapy to decrease and maintain serum uric acid levels below the upper limits of normal.
- Recognize that acute gouty attacks during long-term treatment of gout require acute treatment as well as prophylaxis.
| | Drug Treatment of Gout (table)
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Recognize that optimal management of acute gout requires control of inflammation as well as pain relief.  |
- Consider treatment with nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, colchicine, and analgesics, alone or in combination, to manage acute gout.
- Use NSAIDs or narcotics (or both) for adequate analgesia.
- Note that the choice of agents for acute gout depends largely on patient characteristics and especially on the presence or absence of concomitant disease.
- Be aware that traditional NSAIDs have usually been the first-line therapy owing to their combined analgesic and anti-inflammatory effects; newer cyclooxygenase-2-selective NSAIDs have similar efficacy but have not been widely studied as treatment of acute gout.
- Use corticosteroids when NSAIDs are deemed unsafe in elderly persons, patients with renal insufficiency or active GI ulceration, and those receiving concurrent anticoagulation or other interacting drugs, or after surgery.
- Use a local steroid injection of a single involved joint (e.g., knee, ankle, elbow, or wrist) if other interventions have been ineffective or are relatively contraindicated.
- Do not give NSAIDs to patients with renal insufficiency or elderly persons with other risk factors for NSAID gastropathy.
- Do not give full dose colchicine to patients with renal insufficiency.
- Be aware that patients with peptic ulcer disease may not tolerate NSAIDs.
- Recognize that patients with diabetes may develop increasing hyperglycemia while taking corticosteroids.
- See table Drug Treatment of Gout
- See table Commonly Used Nonsteroidal Anti-inflammatory Drugs in Treatment of Acute Gout.
| Background | Back to top
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Recognize that effective management of recurrent gout attacks or chronic gout (monosodium urate deposition) requires drug therapy to decrease and maintain serum uric acid levels below the upper limits of normal. |
- In patients with recurrent acute attacks or more than 1 or 2 acute attacks in 1 year:
- Administer uric acid-lowering agents to achieve a serum uric acid level <5 mg/dL, if possible
- Recognize that therapy may be required lifelong
- Consider 24-hour urinalysis quantitating uric acid secretion and creatinine to identify whether the patient is an “undersecretor” of uric acid (<600 mg/d while consuming a low-purine diet)
- Use uricosuric agents or xanthine oxidase inhibitors (or both) to decrease uric acid levels; if urate oxidase becomes available in the United States, it may be an alternative method of decreasing urate levels in patients who are intolerant of other therapies
- Do not initiate treatment with any uric acid-lowering agents during an acute gout attack; wait for 1 or 2 weeks for the attack to completely resolve
- Consider using colchicine to prevent acute gout attacks when initiating uric acid-lowering therapy
- When providing patients with uric acid-lowering therapy with uricosurics:
- Consider initiating treatment with uricosuric agents in patients who are probably secreting <600 mg of uric acid daily while consuming a low-purine diet
- Note that uricosurics are generally not effective in patients with renal insufficiency and a creatinine clearance <40 mL/min, necessitating use of allopurinol
- Do not use uricosuric agents in patients with nephrolithiasis
- Recognize that once-daily xanthine oxidase inhibitors may be more convenient for patients and may increase adherence to therapy
- Consider the following when using uric acid-lowering therapy with xanthine oxidase inhibitors (allopurinol or febuxostat):
- When initiating treatment with allopurinol:
- Begin with half the projected dose, increasing to the full projected dose in 4 to 6 weeks to minimize gout exacerbations
- Use a lower projected dose in patients with renal insufficiency
- Caution patients to immediately report side effects, such as rash
- When initiating treatment with febuxostat:
- Begin with half the projected dose, increasing to the full projected dose in 4 to 6 weeks to minimize gout exacerbations
- Do not adjust dosage for age, renal function, or gender
- See table Drug Treatment of Gout.
| Background | Back to top
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Recognize that acute gouty attacks during long-term treatment of gout require acute treatment as well as prophylaxis. |
- Treat acute gout attacks (see information on optimal management of acute gout) during long-term management.
- Consider prophylaxis with colchicine or NSAIDs to reduce the number and severity of attacks during initiation of uric acid-lowering therapies.
- Consider continuing long-term therapy with colchicine if attacks are frequent despite ongoing uric acid-lowering therapy.
| Background | Back to top
| | | FAQs |
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| Grace P. Teal, MD (deceased) has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Howard A. Fuchs, MD, is a consultant for TAP Pharmaceuticals.
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott. |
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PIER is copyrighted (c) 2009 by the American College of Physicians,
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Gout
