From the Guidelines
Chronic low-grade gout symptoms in the toe should be managed with urate-lowering therapy (ULT) and non-pharmacological approaches, with allopurinol as the first-line ULT, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. To manage chronic low-grade gout symptoms in the toe, the following approaches can be considered:
- Urate-lowering therapy (ULT) should be considered from the first presentation of the disease, with the goal of maintaining serum uric acid (SUA) levels at <6 mg/dL (360 mmol/L) and <5 mg/dL (300 mmol/L) in those with severe gout 1.
- Allopurinol is recommended as the first-line ULT, with its dosage adjusted according to renal function 1.
- For patients who cannot achieve the SUA target with allopurinol, febuxostat, a uricosuric, or combining a xanthine oxidase inhibitor with a uricosuric should be considered 1.
- Non-pharmacological management approaches, such as education, lifestyle changes, and dietary modifications, should also be implemented to help manage gout symptoms.
- Patients should be advised to drink plenty of water, limit alcohol consumption, and reduce intake of purine-rich foods.
- Maintaining a healthy weight and avoiding fasting or crash diets that can trigger flares is also important.
- During acute episodes, applying ice to the affected toe and wearing comfortable shoes that don't put pressure on the joint can help alleviate symptoms.
From the FDA Drug Label
KRYSTEXXA® (pegloticase) is a PEGylated uric acid specific enzyme indicated for the treatment of chronic gout in adult patients refractory to conventional therapy Gout refractory to conventional therapy occurs in patients who have failed to normalize serum uric acid and whose signs and symptoms are inadequately controlled with xanthine oxidase inhibitors at the maximum medically appropriate dose or for whom these drugs are contraindicated.
The treatment for chronic low-grade gout symptoms in the toe is pegloticase (IV), which is indicated for the treatment of chronic gout in adult patients refractory to conventional therapy 2.
- The recommended dose and regimen of KRYSTEXXA for adult patients is 8 mg given as an intravenous infusion every two weeks.
- Allopurinol (PO) can also be used to treat gout, but it is recommended to start with a low dose and increase at weekly intervals until a serum uric acid level of 6 mg/dL or less is attained 3.
- Probenecid (PO) is indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis 4.
From the Research
Treatment Options for Chronic Low-Grade Gout Symptoms in the Toe
- Urate-lowering therapies (ULTs) are recommended for the treatment of gout, with the goal of lowering serum uric acid (sUA) concentrations to below 6 mg/dL 5.
- Available ULTs include xanthine-oxidase inhibitors such as allopurinol and febuxostat, as well as uricosuric agents like benzbromarone and probenecid 5, 6.
- Febuxostat has been shown to be more effective than allopurinol in lowering sUA concentrations, with 70.7% of patients reaching the target sUA level compared to 44.4% with allopurinol 5.
- Allopurinol is generally considered a safe option, with a similar incidence of adverse events compared to febuxostat 7.
- The choice of ULT should be individualized based on patient factors such as renal function, comorbidities, and patient preference 6, 8.
Management of Gout Flares
- Acute gout flares can be treated with anti-inflammatory medications such as colchicine, NSAIDs, and corticosteroids 6, 8.
- IL-1 inhibitors are a new option for the treatment of gout flares that are refractory to standard therapies 6.
- Prophylaxis of gout flares can be achieved with ULTs, with the goal of preventing future flares by lowering sUA concentrations 6, 8.