What is the management of chronic gout?

From the Guidelines

The management of chronic gout should focus on long-term urate-lowering therapy (ULT) to reduce serum uric acid levels below 6 mg/dL, with allopurinol as the preferred first-line treatment, starting at a low dose of 100 mg daily and gradually increasing until target uric acid levels are achieved, as recommended by the 2020 American College of Rheumatology guideline 1.

Key Recommendations

• First-line treatment with allopurinol, starting at a low dose of 100 mg daily, with gradual increases until target uric acid levels are achieved, with maximum doses up to 800 mg daily.
• For patients who cannot tolerate allopurinol, febuxostat (40-80 mg daily) is an alternative.
• Probenecid (250-500 mg twice daily) may be used as an alternative or in combination with xanthine oxidase inhibitors.
• When initiating ULT, prophylactic therapy with colchicine (0.6 mg once or twice daily), low-dose NSAIDs, or low-dose prednisone (≤10 mg daily) should be given for 3-6 months to prevent flares.
• Lifestyle modifications, including weight loss if overweight, limiting alcohol (especially beer), reducing intake of purine-rich foods like red meat and seafood, and avoiding high-fructose corn syrup, are also important.

Monitoring and Adjustments

• Regular monitoring of serum uric acid levels every 6-12 months helps ensure treatment effectiveness and may guide dose adjustments.
• ULT is typically lifelong, as discontinuation often leads to recurrence of gout attacks.
• Management of comorbidities such as hypertension, diabetes, and kidney disease is essential. The 2020 American College of Rheumatology guideline 1 provides the most recent and highest quality evidence for the management of chronic gout, and its recommendations should be followed to optimize patient outcomes.

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 management of chronic gout involves the use of pegloticase (IV), a PEGylated uric acid specific enzyme, in adult patients who are refractory to conventional therapy. This includes patients who have failed to normalize serum uric acid levels 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 2, 3, 4.

• Key points: + Pegloticase (IV) is 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. + Pegloticase (IV) should be administered in a healthcare setting by healthcare providers prepared to manage infusion reactions. + Patients should be pre-treated with antihistamines and corticosteroids. + Gout flare prophylaxis with a non-steroidal anti-inflammatory drug (NSAID) or colchicine is recommended starting at least 1 week before initiation of pegloticase (IV) therapy and lasting at least 6 months, unless medically contraindicated or not tolerated.

From the Research

Management of Chronic Gout

The management of chronic gout involves several key components, including:

• Urate lowering therapy (ULT) to reduce serum urate levels and prevent the formation of monosodium urate crystals 5, 6, 7
• Prophylaxis to prevent gout flares 6, 8
• Education and lifestyle modifications to reduce the risk of gout flares and improve overall health 9
• Assessment and management of comorbid conditions, such as cardiovascular disease and renal dysfunction 6, 9

Urate Lowering Therapy

ULT is a crucial component of chronic gout management, with the goal of reducing serum urate levels to less than 6 mg/dL 5. Several ULT options are available, including:

• Xanthine-oxidase inhibitors, such as allopurinol and febuxostat 5, 7
• Uricosuric agents, such as lesinurad 7
• Combination therapy, such as lesinurad plus allopurinol or febuxostat 7

Prophylaxis

Prophylaxis is an important aspect of chronic gout management, with the goal of preventing gout flares 6, 8. Several prophylactic options are available, including:

• Low-dose anti-inflammatory therapies, such as colchicine or NSAIDs 6
• Corticosteroids 6
• Anti-IL-1β biological therapy 6

Education and Lifestyle Modifications

Education and lifestyle modifications are essential for effective chronic gout management 9. Patients should be educated on:

• The importance of adhering to ULT and prophylaxis regimens
• Lifestyle modifications to reduce the risk of gout flares, such as dietary changes and weight loss
• The importance of regular monitoring and follow-up with healthcare providers

Assessment and Management of Comorbid Conditions

Comorbid conditions, such as cardiovascular disease and renal dysfunction, should be assessed and managed as part of chronic gout management 6, 9. This may involve:

• Regular monitoring of cardiovascular risk factors and renal function
• Management of comorbid conditions with medications or lifestyle modifications
• Referral to specialist care as needed