What are the Philippine guidelines for managing gout?

Philippine Guidelines for Managing Gout

The management of gout in the Philippines should follow a treat-to-target strategy with urate-lowering therapy (ULT) aimed at achieving serum uric acid levels below 6 mg/dL, starting with allopurinol as first-line therapy. 1, 2

Diagnosis

• Definitive diagnosis requires identification of monosodium urate (MSU) crystals in synovial fluid
• If crystal identification is not possible, diagnosis can be supported by:
  • Classical clinical features (podagra, tophi, rapid response to colchicine)
  • Characteristic imaging findings 1

Management of Acute Gout Flares

First-line options:

1. NSAIDs:

   • Naproxen 500mg twice daily
   • Avoid in patients with severe renal impairment 2

2. Colchicine:

   • Low-dose regimen: 1.2mg initially, followed by 0.6mg after 1 hour
   • More effective when started within 12 hours of symptom onset
   • Dose adjustment for renal impairment:
     • For CrCl 30-50 mL/min: No dose adjustment but monitor closely
     • For severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks
     • For dialysis patients: Single dose of 0.6mg, not repeated more than once every two weeks 3

3. Corticosteroids:

   • Oral: Prednisone 30-35mg daily for 3-5 days
   • Intra-articular: Particularly effective for 1-2 large joints
   • Intramuscular: Option for patients who cannot take oral medications 1, 2

For severe polyarticular flares:

• Consider combination therapy with two modalities at full doses:
  • NSAIDs + colchicine
  • Oral corticosteroids + colchicine
  • Intra-articular injections with another modality 2

Long-term Management

Urate-Lowering Therapy (ULT)

Indications for ULT:

• Recurrent gout attacks (≥2 per year)
• Presence of tophi
• Radiographic damage due to gout
• Chronic kidney disease 1, 2

First-line ULT:

• Allopurinol:
  • Starting dose: 100mg daily (lower in renal insufficiency)
  • For mild-moderate renal impairment: Start at 50-100mg daily
  • For CrCl 10-20 mL/min: 200mg daily
  • For CrCl <10 mL/min: Not to exceed 100mg daily
  • Gradually titrate dose to achieve target serum urate 4

Alternative ULT options:

• Febuxostat: Consider when allopurinol is not tolerated or contraindicated
• Uricosurics (e.g., benzbromarone, probenecid): Consider as second-line options 1

Target serum urate level:

• <6 mg/dL (360 μmol/L) for most patients
• <5 mg/dL (300 μmol/L) for patients with tophi 1, 2

Prophylaxis During ULT Initiation

• Essential to prevent paradoxical flares during ULT initiation
• Options include:
  • Colchicine 0.5-1.0mg daily
  • Low-dose NSAIDs
  • Low-dose prednisone (approximately 7.5mg daily)
• Duration: 3-6 months after starting ULT 1, 2

Lifestyle Modifications

• Weight loss for overweight or obese patients
• Limit consumption of:
  • Purine-rich foods (organ meats, shellfish)
  • Alcoholic beverages (especially beer)
  • Beverages sweetened with high-fructose corn syrup 2, 5
• Encourage consumption of:
  • Low-fat dairy products
  • Vegetables
  • Adequate hydration (at least 2 liters daily) 2, 6
• Regular moderate physical activity 2

Special Considerations for Filipino Patients

Filipino patients may have specific considerations in gout management:

• Studies have shown a lower mean of serum uric acid values in healthy Filipino subjects 7
• Some Filipino patients may have a renal defect leading to hyperuricemia when transitioning from traditional Filipino diet to Western diet 7
• A recent study at the University of the Philippines-Philippine General Hospital showed only 37.7% of patients achieved target serum urate levels at 6 months of ULT 8
• Factors associated with achieving target levels included:
  • BMI >25 kg/m²
  • Allopurinol dose ≥300mg
  • Lower baseline serum uric acid levels 8

Monitoring

• Regular monitoring of serum uric acid levels to ensure target levels are maintained
• Monitor for frequency of gout attacks and resolution of tophi
• Assess renal function before and during therapy 1, 2

Common Pitfalls to Avoid

1. Inadequate ULT dosing: Many Filipino patients require allopurinol doses ≥300mg to achieve target serum urate levels 8
2. Failure to provide prophylaxis when initiating ULT: This can lead to increased flares and poor medication adherence
3. Not considering drug interactions: Particularly with colchicine and CYP3A4 inhibitors
4. Ignoring renal function: Dose adjustments are crucial for patients with renal impairment
5. Poor patient education: Explaining the importance of long-term ULT despite absence of symptoms is essential for adherence

By following these guidelines, healthcare providers in the Philippines can effectively manage gout and improve patient outcomes by reducing flare frequency, preventing complications, and enhancing quality of life.