What is the initial treatment for a patient with gout (a form of inflammatory arthritis) and uveitis (inflammation of the uvea in the eye)?

Initial Treatment for Gout Uveitis

For patients with gout and uveitis, the initial treatment should include topical prednisolone acetate 1% eye drops for the uveitis component, along with appropriate gout management including NSAIDs, colchicine, or corticosteroids for acute gout attacks, and urate-lowering therapy for long-term management. 1

Treatment Approach for Uveitis Component

First-Line Treatment

• Topical glucocorticoids:
  • Prednisolone acetate 1% eye drops is the preferred agent 1
  • Initial dosing may require more than 1-2 drops/eye/day, but this increases risk for ocular complications
  • Goal is to use topical glucocorticoids as short-term therapy (≤3 months) to control inflammation

Monitoring

• Ophthalmologic examination within 1 month after each change in topical glucocorticoid therapy 1
• Regular monitoring no less frequently than every 3 months while on stable therapy

When to Escalate Therapy

• If requiring 1-2 drops/day of prednisolone acetate 1% for ≥3 months:
  • Add systemic therapy to allow tapering of topical glucocorticoids 1
  • This approach reduces risk of glucocorticoid-related complications such as cataracts and glaucoma

Systemic Therapy Options

For Persistent Uveitis

If topical therapy is insufficient after 3 months, consider:

1. Methotrexate (preferred first-line systemic agent)

   • Subcutaneous administration is preferred over oral 1

2. Other DMARDs options:

   • Mycophenolate
   • Leflunomide
   • Cyclosporine

3. Biologic agents (for refractory cases):

   • Monoclonal TNF inhibitors (adalimumab, infliximab) are preferred over etanercept 1
   • Consider for severe cases with sight-threatening complications

Treatment for Gout Component

Acute Gout Attack Management

• NSAIDs, colchicine, or corticosteroids are equally efficacious 2
  • Selection should be guided by patient comorbidities

Long-term Management

• Urate-lowering therapy:
  • Allopurinol (dose based on renal function) 2
  • Febuxostat (alternative xanthine oxidase inhibitor) 2
  • Uricosuric drugs like probenecid (increases uric acid excretion) 2

Treatment Goals and Monitoring

Goals of Therapy

• Control of ocular inflammation
• Prevention of vision loss
• Reduction of systemic corticosteroid dose to ≤7.5 mg/day (if systemic steroids are used) 3
• Reduction of serum uric acid to target levels for gout management

Potential Pitfalls and Caveats

1. Chronic systemic corticosteroid therapy is not acceptable as a long-term treatment plan for uveitis 4

   • Steroid-sparing immunosuppressive therapy should be pursued once acute inflammation is controlled

2. Delayed treatment escalation can lead to:

   • Ciliary body dysfunction
   • Inadequate aqueous production
   • Chorioretinal damage
   • Potential blindness 4

3. Inadequate monitoring may miss:

   • Early signs of treatment failure
   • Development of ocular complications
   • Medication side effects

4. Failure to address both conditions simultaneously can lead to suboptimal outcomes

By following this treatment algorithm, clinicians can effectively manage both the ocular inflammation associated with uveitis and the underlying gout, minimizing the risk of vision loss and improving quality of life for these patients.