Treatment of Gout Tophi
The primary treatment for gout tophi is achieving a sustained reduction in serum uric acid, preferably below 0.30 mmol/L (5 mg/dL), through urate-lowering therapy (ULT). 1
Pharmacological Management
First-Line Therapy
- Allopurinol should be the first-line urate-lowering therapy for patients with tophi 1
- Start allopurinol at a low dose (≤100 mg daily, and lower in patients with chronic kidney disease) 1
- Gradually titrate the dose upward every 2-5 weeks until reaching the serum urate target 1
- The maintenance dose of allopurinol can exceed 300 mg daily, even in those with renal impairment, with appropriate monitoring 1
Alternative ULT Options
- Febuxostat is an alternative first-line agent if allopurinol is not tolerated or contraindicated 1
- Consider switching from febuxostat to an alternative ULT in patients with a history of cardiovascular disease 1
- Uricosurics (e.g., benzbromarone, probenecid) can be considered as second-line options 1
- For patients with severe tophaceous gout where other ULT options have failed, pegloticase can be considered 2
Treatment Target
- The minimum serum urate target should be <6 mg/dL (0.36 mmol/L) 1
- For patients with tophi, a more aggressive target of <5 mg/dL (0.30 mmol/L) is recommended to accelerate tophi resolution 1, 3
Monitoring and Follow-up
- Regular monitoring of serum urate levels (every 2-5 weeks during ULT titration, then every 6 months once target is achieved) 1
- Monitor for adverse events, especially during allopurinol initiation and dose escalation 1
- Assess tophi size and resolution as part of ongoing clinical evaluation 1
Flare Prophylaxis During ULT Initiation
- When starting ULT, prophylaxis against gout flares is essential 1
- Use colchicine (up to 1.2 mg daily) as first-line prophylaxis 1
- If colchicine is contraindicated or not tolerated, low-dose NSAIDs or glucocorticoids can be used 1
- Duration of prophylaxis depends on individual patient factors 1
Special Considerations
Genetic Testing
- Consider HLA-B*5801 testing prior to starting allopurinol in patients of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and African American patients due to higher risk of severe hypersensitivity reactions 1
Surgical Management
- Surgery for tophi is only indicated in selected cases such as nerve compression, mechanical impingement, or infection 1
- Medical management with ULT should be the primary approach 1
Duration of Therapy
- ULT should be continued indefinitely rather than stopped once tophi have resolved 1
- Discontinuation of ULT frequently leads to recurrence of gout flares 1
Common Pitfalls to Avoid
- Starting allopurinol at too high a dose increases the risk of hypersensitivity reactions 1
- Failing to provide prophylaxis against flares when initiating ULT 1
- Stopping ULT during acute gout attacks (ULT should be continued) 4
- Inadequate dose titration leading to failure to achieve target serum urate levels 1, 4
- Poor patient education and follow-up, which leads to reduced adherence and treatment failure 4