From the Guidelines
Managing gout in patients starting tirzepatide requires proactive monitoring and treatment, with a focus on continuing existing gout medications and considering the initiation of urate-lowering therapy (ULT) with allopurinol or febuxostat, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. When initiating tirzepatide, patients should continue their existing gout medications, such as allopurinol, febuxostat, or probenecid. For those with a history of gout but not on preventive therapy, consider starting allopurinol (100mg daily, titrating up to 300mg daily as needed) or febuxostat (40mg daily, increasing to 80mg if necessary) before or simultaneously with tirzepatide, as these are the preferred first-line ULT agents, including for those with moderate-to-severe chronic kidney disease (CKD; stage ≥3) 1. Some key points to consider when managing gout in patients starting tirzepatide include:
- Monitoring uric acid levels at baseline and 3 months after starting tirzepatide, aiming for levels below 6 mg/dL, as part of a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements 1.
- Using concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months when initiating ULT, with options including colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) 1.
- Managing acute gout flares during tirzepatide initiation with colchicine (0.6mg once or twice daily), NSAIDs like naproxen (500mg twice daily), or prednisone (20-40mg daily for 3-5 days, then taper) while continuing tirzepatide, as these are strongly recommended for the management of gout flares 1.
- Encouraging adequate hydration (2-3 liters daily), limiting purine-rich foods, and avoiding alcohol to help minimize flare risk during treatment. Tirzepatide can cause rapid weight loss, which may mobilize uric acid from tissues and trigger gout flares, and its effects on renal function may temporarily affect uric acid excretion, highlighting the importance of proactive monitoring and treatment in patients with gout starting tirzepatide.
From the Research
Gout Flare Incidence after Starting Tirzepatide
- There are no direct research papers on the incidence of gout flares after starting tirzepatide, a dual GIP and GLP-1 receptor agonist.
- However, studies have investigated the management of gout in patients with various comorbidities and medications 2, 3, 4, 5.
Management of Gout in Patients Initiated on Tirzepatide
- Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and glucocorticoids are commonly used to treat acute gout flares 2, 3, 4.
- Urate-lowering therapy, such as allopurinol and febuxostat, is used to prevent gout flares in patients with chronic gout 3, 4.
- The safety of colchicine and NSAID prophylaxis when initiating urate-lowering therapy for gout has been evaluated, with results showing an increased risk of adverse events with colchicine and NSAID prophylaxis 5.
Pharmacokinetics of Tirzepatide in Patients with Renal Impairment
- A study evaluated the pharmacokinetics of tirzepatide in subjects with renal impairment versus healthy subjects with normal renal function, and found that tirzepatide exposure was similar across renal impairment groups and healthy subjects 6.
- The study suggested that dose adjustment may not be required for patients with renal impairment 6.
Considerations for Managing Gout in Patients on Tirzepatide
- Patients with gout who are initiated on tirzepatide should be monitored for gout flares and adjusted accordingly 2, 3, 4.
- The use of NSAIDs, colchicine, and glucocorticoids should be considered for the treatment of acute gout flares in patients on tirzepatide 2, 3, 4.
- Urate-lowering therapy should be considered for patients with chronic gout who are on tirzepatide 3, 4.