From the Guidelines
The recommended treatment for tophus gout is urate-lowering therapy (ULT) to dissolve tophi and prevent further crystal formation, with a strong recommendation to initiate ULT in patients with 1 or more subcutaneous tophi, as stated in the 2020 American College of Rheumatology guideline for the management of gout 1.
Key Considerations
- First-line medication is typically allopurinol, starting at 100mg daily and gradually increasing to achieve a serum uric acid level below 6 mg/dL (or below 5 mg/dL for severe tophaceous gout) 1.
- Febuxostat (40-80mg daily) is an alternative for those who cannot tolerate allopurinol, as recommended in the 2017 updated EULAR evidence-based recommendations for the management of gout 1.
- Treatment must be continued long-term, often for years, as tophi dissolve slowly.
- When starting ULT, prophylactic medication (colchicine 0.6mg daily or low-dose NSAIDs) should be used for 3-6 months to prevent flares, as suggested in the 2017 updated EULAR evidence-based recommendations for the management of gout 1.
Lifestyle Modifications
- Weight loss if overweight
- Limiting alcohol (especially beer)
- Avoiding high-purine foods
- Staying well-hydrated
- Regular exercise and a balanced diet, including low-fat dairy products, as recommended in the 2017 updated EULAR evidence-based recommendations for the management of gout 1.
Additional Considerations
- Large or problematic tophi may occasionally require surgical removal.
- The goal of treatment is to maintain consistently low uric acid levels, as this allows the body to gradually dissolve the urate crystal deposits that form tophi.
- It is essential to monitor serum uric acid levels and adjust treatment accordingly to achieve the target level, as recommended in the 2020 American College of Rheumatology guideline for the management of gout 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 tophus gout is pegloticase (IV), with a dosing regimen of 8 mg every 2 weeks, as it has been shown to achieve a complete response in 45% of patients at Month 6 2.
- Colchicine (PO) is not recommended for the treatment of tophi, but rather for the prophylaxis and treatment of gout flares 3.
From the Research
Tophus Gout Treatment
The recommended treatment for tophus gout involves a combination of urate-lowering therapy and anti-inflammatory medications.
- Urate-lowering therapy aims to reduce serum urate levels, which can help dissolve urate crystals and prevent further tophi formation.
- Medications such as allopurinol, febuxostat, and pegloticase have been shown to be effective in reducing tophi 4, 5, 6.
- Achieving a lower serum urate level can lead to a faster rate of tophi reduction 4.
- Surgical interventions may also be considered for patients with large or painful tophi, and can improve pain and function 4.
Urate-Lowering Therapy
Urate-lowering therapy is a crucial component of tophus gout treatment.
- Allopurinol is a commonly used urate-lowering therapy, and is often the first-line treatment for gout 5, 6.
- Febuxostat is another effective urate-lowering therapy, but may be associated with increased cardiovascular risk 5, 6.
- Pegloticase is a highly effective urate-lowering therapy, but may be immunogenic and require co-therapy to achieve sustained efficacy 4, 5.
Anti-Inflammatory Medications
Anti-inflammatory medications may be used to manage acute gout flares and prevent further inflammation.