| Treatment recommendations for gout | |
| Agents used for gout | Dosing/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(Drug information on 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(Drug information on celecoxib) efficacy. |
| Pegloticase | 12 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(Drug information on amlodipine), nifedipine(Drug information on nifedipine) | Do not increase the likelihood of gouty attacks; both losartan(Drug information on losartan) and nifedipine may lower uric acid levels. |
| Low-dose aspirin(Drug information on aspirin), cyclosporine, thiazides | Increase likelihood of gouty attacks. Relative risk for gouty attacks with antihypertensives: 0.87, calcium channel blockers; 0.81, losartan; 2.36, diuretics; 1.48, ß-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, Rodríguez 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.
