From the Guidelines
The recommended treatment for gouty tophi involves a combination of urate-lowering therapy (ULT) and anti-inflammatory medications, with the goal of maintaining serum uric acid levels below 6 mg/dL, as strongly recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
Key Recommendations
- First-line ULT includes allopurinol (starting at 100mg daily and gradually increasing to 300-600mg daily) or febuxostat (40-80mg daily), with the goal of maintaining serum uric acid levels below 6 mg/dL (or below 5 mg/dL for severe cases with extensive tophi) 1.
- During ULT initiation, anti-inflammatory prophylaxis with colchicine (0.6mg once or twice daily), low-dose NSAIDs, or low-dose prednisone (5-10mg daily) should be used for 3-6 months to prevent flares 1.
- For patients with refractory tophi, pegloticase (8mg IV every 2 weeks) may be considered, as recommended by the 2012 American College of Rheumatology guidelines for management of gout 1.
Lifestyle Modifications
- Weight loss if overweight
- Limiting alcohol (especially beer)
- Avoiding high-purine foods
- Staying well-hydrated
Surgical Removal of Tophi
- Generally reserved for cases with severe pain, joint deformity, nerve compression, or skin ulceration.
Successful Treatment
- Requires patience, as tophi dissolution typically takes months to years of consistent ULT therapy to achieve complete resolution. The 2020 American College of Rheumatology guideline for the management of gout provides the most recent and highest quality evidence for the treatment of gouty tophi, and its recommendations should be prioritized in clinical practice 1.
From the FDA Drug Label
The effect of treatment on tophi was a secondary efficacy endpoint and was assessed using standardized digital photography, image analysis, and a Central Reader blinded to treatment assignment. Approximately 70% of patients had tophi at baseline. A pooled analysis of data from Trial 1 and Trial 2 was performed as pre-specified in the protocols At Month 6, the percentage of patients who achieved a complete response (defined as 100% resolution of at least one target tophus, no new tophi appear and no single tophus showing progression) was 45%, 26%, and 8%, with KRYSTEXXA 8 mg every 2 weeks, KRYSTEXXA 8 mg every 4 weeks, and placebo, respectively
The recommended treatment for gouty tophi is pegloticase (IV), with a dose of 8 mg every 2 weeks. This treatment has been shown to achieve a complete response in 45% of patients at Month 6, defined as 100% resolution of at least one target tophus, no new tophi, and no single tophus showing progression 2.
- Key points:
- Pegloticase 8 mg every 2 weeks is the most effective dose for treating gouty tophi.
- Approximately 70% of patients had tophi at baseline.
- A complete response was achieved in 45% of patients at Month 6.
- Note: The use of pegloticase should be considered for patients with chronic gout refractory to conventional therapy, and the treatment should be administered under the guidance of a healthcare professional.
From the Research
Gouty Tophi Treatment
- The recommended treatment for gouty tophi includes urate-lowering therapy (ULT) such as allopurinol, benzbromarone, febuxostat, or pegloticase 3, 4, 5.
- Achieving lower serum urate levels is associated with a faster reduction of tophi 3.
- Pegloticase has been shown to be effective in reducing tophi, but it is associated with a high risk of adverse infusion reactions 4, 5.
- Lesinurad 400 mg plus febuxostat may be beneficial for tophi resolution compared to lesinurad 200 mg plus febuxostat, but there is no difference in adverse events between these groups 5.
- Allopurinol is an agent of first choice for urate lowering therapy, but it has worse persistence rates than febuxostat among patients with gout 6, 7.
- Febuxostat is another efficacious urate lowering therapy, but it has received a U.S. FDA black box warning for cardiovascular safety 6.
- Surgical removal of tophi is also an option, but there is limited evidence on its effectiveness 4.
Treatment Options
- Urate-lowering therapy (ULT) with xanthine oxidase inhibitors (XOIs) such as allopurinol and febuxostat is the cornerstone of gout treatment 7.
- Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity significantly threatens the achievement of sustained urate lowering responses 6.
- Novel uricosurics such as verinurad and arhalofenate are agents with future promise for gout treatment 6.
- Lifestyle modifications form a part of gout prevention, and NSAIDs, colchicine, and glucocorticoids are first line agents for gout flares 6.