From the Guidelines
The treatment for tophaceous gout should focus on reducing urate crystal deposits through long-term urate-lowering therapy (ULT) with a target serum uric acid level below 6 mg/dL, or below 5 mg/dL for severe tophaceous gout, as recommended by the 2020 American College of Rheumatology guideline 1.
Key Recommendations
- First-line medication is typically allopurinol, starting at 100mg daily and gradually increasing to achieve the target serum uric acid level.
- Alternative medications include febuxostat (40-80mg daily) if allopurinol is not tolerated or contraindicated.
- For severe cases, pegloticase may be administered intravenously every two weeks.
- During ULT initiation, prophylactic medications like 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 gout flares.
Lifestyle Modifications
- Weight loss if overweight
- Limiting alcohol intake
- Avoiding high-purine foods
- Staying well-hydrated
Monitoring and Safety
- Regular monitoring of serum uric acid levels and kidney function is essential to ensure treatment effectiveness and safety.
- Tophaceous gout requires long-term (often lifelong) ULT adherence, as tophi dissolve slowly over months to years with consistent therapy. The 2020 American College of Rheumatology guideline provides the most recent and highest quality evidence for the management of gout, including tophaceous gout 1. The previous guideline from 2017 also provides relevant recommendations, but the 2020 guideline supersedes it 1. Other studies, such as the 2014 multinational evidence-based recommendations, also support the use of ULT and lifestyle modifications for the management of gout, but are less recent and therefore less prioritized 1.
From the FDA Drug Label
The average is 200 to 300 mg/day for patients with mild gout and 400 to 600 mg/day for those with moderately severe tophaceous gout The treatment for tophaceous gout is allopurinol (PO) with a dosage of 400 to 600 mg/day.
- The dosage may be administered in divided doses or as a single equivalent dose.
- To reduce the possibility of flare-up of acute gouty attacks, it is recommended that the patient start with a low dose of allopurinol tablets (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained but without exceeding the maximal recommended dosage 2.
From the Research
Tophaceous Gout Treatment
- Tophaceous gout is a condition where urate crystals accumulate in the joints and surrounding tissues, leading to the formation of tophi [ 3 ].
- The primary treatment for tophaceous gout is urate-lowering therapy (ULT), which aims to reduce serum uric acid levels and prevent further formation of tophi [ 4, 5 ].
- Medications used for ULT include allopurinol, febuxostat, probenecid, lesinurad, and pegloticase [ 4, 5, 3 ].
Medical Management
- Allopurinol and febuxostat are commonly used as first-line agents for ULT [ 4, 5 ].
- Colchicine is used to treat acute gout flares, while IL-1 inhibitors are used for flare refractory to standard therapies [ 4 ].
- Lifestyle modifications, such as dietary changes and weight loss, can also help prevent gout flares [ 5 ].
Surgical Intervention
- In rare cases, surgical intervention may be necessary for patients with tophaceous gout who have developed significant complications, such as infection, ulceration, or entrapment neuropathy [ 3 ].
- Surgery may also be considered for patients who have a contraindication to all available ULTs or have not responded to medical therapy [ 3 ].
- The reported outcomes of surgical interventions for tophaceous gout are generally positive, with minimal post-surgical complications [ 3 ].