Should urate lowering therapy be initiated during an acute gout attack?

Urate Lowering Therapy During Acute Gout Attack

Ongoing urate lowering therapy (ULT) should be continued without interruption during an acute gout attack, but initiating new ULT during an acute attack is not recommended. 1

Management of ULT During Acute Gout

Continuing Established ULT

• Established pharmacologic ULT should be continued, without interruption, during an acute attack of gout (Evidence C) 1
• Stopping ULT during an acute attack may lead to fluctuations in serum urate levels, potentially prolonging or worsening the attack 1

Initiating New ULT

• ULT should not be initiated during an acute gout attack but rather after the resolution of acute symptoms 1
• The American College of Physicians (ACP) recommends against initiating long-term ULT in most patients after a first gout attack or in patients with infrequent attacks (<2 per year) 1
• ULT is indicated in patients with:
  • Recurrent acute attacks (≥2 episodes per year) 1
  • Gouty arthropathy 1
  • Presence of tophi 1
  • Radiographic changes of gout 1
  • Associated uric acid nephrolithiasis 1

Acute Gout Attack Management

First-Line Treatment Options

• NSAIDs, oral colchicine, or corticosteroids are appropriate first-line options for treatment of acute gout attacks 1
• Treatment should be initiated within 24 hours of symptom onset for optimal outcomes 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg 1 hour later) is as effective as higher doses with fewer gastrointestinal adverse effects 1

Combination Therapy

• Combination therapy may be appropriate for severe or refractory attacks 1
• Inadequate response is defined as <20% improvement in pain score within 24 hours or <50% improvement at ≥24 hours 1

Starting ULT After Acute Attack Resolution

Timing of ULT Initiation

• ULT should be started after complete resolution of the acute gout attack 1
• There is no specific evidence on the optimal time to start ULT after an acute attack 2

Prophylaxis When Starting ULT

• Pharmacologic anti-inflammatory prophylaxis is recommended for all gout patients when initiating ULT 1
• Prophylaxis should be continued if there is any clinical evidence of continuing gout disease activity or if the serum urate target has not been achieved 1
• Oral colchicine is appropriate first-line prophylaxis therapy when starting ULT 1
• Low-dose NSAID therapy is an appropriate alternative for prophylaxis 1
• Prophylactic treatment for more than 8 weeks is more effective than shorter durations 1

ULT Dosing Strategy

• When starting allopurinol, begin with a low dose (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of ≤6 mg/dL is attained 3
• The therapeutic goal of ULT is to maintain serum uric acid below the saturation point for monosodium urate (360 μmol/L or 6 mg/dL) 1

Common Pitfalls to Avoid

• Starting ULT during an acute attack may potentially prolong the attack or cause flares 4, 5
• Failing to provide prophylaxis when initiating ULT can lead to acute flares 2
• Interrupting established ULT during an acute attack can worsen outcomes 1
• Not adjusting allopurinol dosage in patients with renal impairment can increase risk of adverse effects 3
• Inadequate duration of prophylaxis when starting ULT (should be continued for at least 6 months) 2