From the Guidelines
The treatment of gouty tophi primarily involves urate-lowering therapy (ULT) to dissolve these crystalline deposits, with a strong recommendation for initiating 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 Recommendations
- First-line medication is allopurinol, typically started at 100mg daily and gradually increased to achieve a serum uric acid level below 6 mg/dL (or below 5 mg/dL for severe cases with multiple tophi) 1.
- Alternative medications include febuxostat (40-80mg daily), which may be used in patients who cannot tolerate allopurinol, and probenecid (250mg twice daily, increasing to 500mg twice daily) for those with normal kidney function 1.
- During initiation of ULT, 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, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
Lifestyle Modifications
- Patients should maintain adequate hydration and follow a low-purine diet, with advice on weight loss if appropriate, avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals, and excessive intake of meat and seafood 1.
- Regular exercise should be advised, and low-fat dairy products should be encouraged, as they have been found to have an inverse association with urate levels 1.
Surgical Intervention
- For large or problematic tophi causing pain, joint deformity, or skin ulceration, surgical removal may be considered, as part of a comprehensive treatment plan 1.
Monitoring and Adherence
- Treatment must be continued indefinitely as ULT dissolves existing tophi but doesn't prevent new formation if therapy is discontinued, with regular monitoring of serum uric acid levels and patient adherence to therapy essential for successful management 1.
From the FDA Drug Label
The mobilization of urates from tissue deposits which cause fluctuations in the serum uric acid levels may be a possible explanation for these episodes Even with adequate therapy with allopurinol tablets, it may require several months to deplete the uric acid pool sufficiently to achieve control of the acute attacks
The treatment for gouty tophi (uric acid deposits) involves adequate therapy with allopurinol to deplete the uric acid pool, which may take several months to achieve control of acute attacks.
- Allopurinol is used to reduce serum uric acid levels.
- Colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases.
- A fluid intake of at least 2 liters per day and maintenance of a neutral or slightly alkaline urine are desirable to help prevent renal precipitation of urates 2.
From the Research
Treatment Options for Gouty Tophi
- Medical therapy with urate-lowering therapies (ULT) such as allopurinol, febuxostat, probenecid, lesinurad, and pegloticase is the first-line approach to treating tophaceous gout 3.
- Pegloticase has been shown to be effective in resolving tophi, with moderate-certainty evidence indicating that biweekly pegloticase infusion reduced tophi in participants with gout 4, 5.
- Lesinurad 400 mg plus febuxostat may be beneficial for tophi resolution, with low-certainty evidence suggesting that it may result in no difference in adverse events compared to lesinurad 200 mg plus febuxostat 5.
- Surgical intervention may be considered for patients with significant complications of tophi, such as infection, ulceration, and entrapment neuropathy, or for those with contraindications to all available ULTs 3.
Urate-Lowering Therapies
- Allopurinol is the most commonly used ULT, but there is no consensus on dosing in renal impairment 6.
- Febuxostat is effective at lowering serum urate, but there are limited data in the elderly and patients with renal impairment 6.
- Probenecid is ineffective in patients with renal impairment, and the availability of benzbromarone is limited due to concerns about its hepatotoxicity 6.
- Recombinant uricases, such as pegloticase, provide an exciting new therapeutic option, but there are limited data for their use in the elderly 6.