New guidelines on management of gout from the American College of Rheumatology focus on the new xanthane oxidase inhibitors and on targets for urate control. They appear in the October edition of Arthritis Care and Research, as two separate articles: On management of hyperuricemia and treatment and prevention of acute gouty arthritis.
Among the highlights:
♦ The target serum urate level for management of hyperuricemia is <6 mg/dl.
♦ Allopurinol may be used at a dosage no greater than 100 mg/day to treat flares early in the course of disease (or <50 mg/day for patients with advanced chronic kidney disease), titrating the dose up to 300 mg/day or higher. Monitor for hypersensitivity, testing for the HLA-B*5801 allele in patients with certain Asian ethnic backgrounds.
♦ Febuxostat (Uloric) may be used to control hyperuricemia. The FDA approves doses no greater than 80 mg/day. (In other countries, doses up to 120 mg/day are used.)
♦ Other options if these drugs fail to provide adequate control: probenecid(Drug information on probenecid) (Benemid), fonofibrate, losartan(Drug information on losartan) (Cozaar), pegloticase (Krystexxa). More work is needed to establish optimal use of these medications.
♦ Treat acute attacks within 24 hours. Start with monotherapy: NSAIDS, colchicine(Drug information on colchicine), or systemic corticosteroids depending on your judgment and patient preference. For severe flares, try combinations.
The guidelines also urge counseling patients about diet and the importance of urate control, and being alert for common comorbidities including kidney disease and cardiovascular disorders, as well as for concomitant use of drugs that influence urate levels (notably thiazide diuretics).