What is the treatment for increased gouty tophi in a joint?

Treatment for Increased Gouty Tophi in a Joint

For patients with increased gouty tophi in a joint, long-term urate-lowering therapy with allopurinol or febuxostat is the cornerstone of treatment, combined with anti-inflammatory prophylaxis during initiation to prevent acute flares. 1, 2

Initial Management of Gouty Tophi

• Urate-lowering therapy (ULT) is the primary treatment for gouty tophi, with allopurinol as first-line therapy to reduce serum uric acid levels and gradually dissolve tophi 1, 3
• Febuxostat is an alternative first-line ULT option, particularly in patients with allopurinol intolerance or contraindications 3, 4
• ULT should be continued without interruption, even during acute gout attacks 2, 3
• The goal of ULT is to maintain serum uric acid below 6 mg/dL to promote dissolution of tophi 3, 5

Anti-inflammatory Prophylaxis During ULT Initiation

• Anti-inflammatory prophylaxis is essential when starting ULT to prevent acute flares triggered by crystal mobilization 2, 6
• First-line prophylactic options include:
  • Low-dose colchicine (0.6 mg daily) 2, 5
  • Low-dose NSAIDs with proton pump inhibitor when indicated 2, 6
• Prophylaxis should be continued for at least 6 months after initiating ULT 2, 5

Management of Acute Flares During Tophi Treatment

If acute flares occur during treatment of tophi:

• Treat promptly with one of the following:
  • NSAIDs at full anti-inflammatory doses 3
  • Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) 3, 6
  • Corticosteroids (oral, intra-articular, or systemic) 3
• Continue ULT without interruption during acute attacks 2, 3
• For severe polyarticular flares, combination therapy may be appropriate 6, 3

Special Considerations for Tophaceous Gout

• Pegloticase (IV) may be considered for patients with severe tophaceous gout refractory to conventional therapy 4
• At 6 months, pegloticase 8 mg every 2 weeks resulted in complete resolution of at least one target tophus in 45% of patients compared to 8% with placebo 4
• Treatment with ULT should continue for at least 6 months after uric acid levels fall below target goal in patients with tophi 5
• Elderly patients with tophi may require lower starting doses of allopurinol (50-100 mg) due to increased risk of adverse effects 7

Monitoring and Duration of Therapy

• Regular monitoring of serum uric acid levels is necessary to ensure target levels are maintained 3, 5
• Treatment should continue indefinitely in patients with tophaceous gout to prevent recurrence 1, 5
• Assess for resolution of tophi visually during follow-up visits 4

Common Pitfalls to Avoid

• Stopping ULT during acute attacks, which can worsen and prolong the attack 2, 3
• Failing to provide prophylaxis when initiating ULT, leading to increased flare frequency 2, 6
• Using high-dose colchicine regimens, which have similar efficacy but significantly more side effects than low-dose regimens 6, 3
• Treating asymptomatic hyperuricemia without clinical gout manifestations 1, 7
• Inadequate duration of ULT, as tophi require prolonged treatment for resolution 5, 4