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Treatment Recommendations for Gout: A Summary Table

Treatment Recommendations for Gout: A Summary Table

 

Treatment recommendations for gout
Agents used for goutDosing/comments
Allopurinol (long-term uric acid lowering)Start slowly (50 - 100 mg/d); titrate up to 800 mg/d. Increase dose every 2 - 4 weeks. To reach target uric acid level of 6 mg/dL, start 2 - 4 weeks after acute attack has resolved. Decrease dose in patients with CKD. Exercise caution in patients with CKD4 or worse.
Febuxostat (long-term uric acid lowering)Daily doses of 80 and 120 mg were, respectively, 2.5 and 3 times more likely to achieve urate levels of < 6 mg/dL as was 300 mg of allopurinol. With creatinine clearances of 30 – 89 ml/min, 80- and 40-mg doses of febuxostat were superior to 200 - 300 mg of allopurinol in lowering uric acid to 6 mg/dL. This is a second-line agent for people who have prohibitive adverse effects with or who fail to respond to allopurinol. Safety data are lacking in patients with advanced CKD.
Colchicine (acute attacks)Use low-dose regimen: 1.2 mg PO followed once by 0.6 mg PO 1 hour later, then stop.a
Corticosteroids (acute attacks)Prednisone, 40 mg/d for 5 days, especially in patients with CKD4 or worse. May be administered intra-articularly if only 1 or 2 joints are involved.
NSAIDs (acute attacks)Avoid in patients with renal, hepatic, cardiac failure or with history of GI bleeding; use with caution in the elderly; use with proton pump inhibitor. There are no data for celecoxib efficacy.
Pegloticase12 biweekly IV infusions for 6 months in patients refractory to conventional treatment for lowering uric acid levels.
Uricosuric drugs (for long-term uric acid lowering)Author avoids (only effective in under-excreters of uric acid).
Other agents that may affect goutb Favored antihypertensives: losartan, amlodipine, nifedipineDo not increase the likelihood of gouty attacks; both losartan and nifedipine may lower uric acid levels.
Low-dose aspirin, cyclosporine, thiazidesIncrease likelihood of gouty attacks. Relative risk for gouty attacks with antihypertensives: 0.87, calcium channel blockers; 0.81, losartan; 2.36, diuretics; 1.48, -blockers; 1.24 ACE inhibitors; 1.29, non-losartan ARBs.
CKD, chronic kidney disease; CKD4, stage 4 chronic kidney disease; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blockers.
a Author does not use for long-term prevention of attacks.
b These agents are not used to treat gout, but their use may have an effect on gout.



References

1. Neogi T. Clinical practice. Gout. N Engl J Med. 2011;364:443-452.
2. Laine C, Turner BJ, Williams S, eds. Gout. Annals of Internal Medicine: In the Clinic. 2010;ITC2.
3. Sundy JS, Baraf HS, Yood RA, et al. Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials. JAMA. 2011;306:711-720.
4. Choi HK, Soriano LC, Zhang Y, Rodrguez LA. Antihypertensive drugs and risk of incident gout among patients with hypertension: population-based case-control study. BMJ. 2012;344:d8190. doi:10.1136/bmj.d8190.
5. Ruilope LM, Kirwan BA, de Brouwer S, et al; ACTION Investigators. Uric acid and other renal function parameters in patients with stable angina pectoris participating in the ACTION trial: impact of nifedipine GITS (gastro-intestinal therapeutic system) and relation to outcome. J Hypertens. 2007;25:1711-1718.

 
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