What is the approach to managing a patient with chronic gout?

Management of Chronic Gout

The management of chronic gout requires a treat-to-target strategy with urate-lowering therapy (ULT) to achieve and maintain serum urate levels below 6 mg/dL, along with prophylaxis against flares during ULT initiation and appropriate lifestyle modifications. 1

Indications for Urate-Lowering Therapy

• ULT is strongly recommended for patients with:
  • Tophaceous gout (clinical or radiographic evidence) 1
  • Frequent gout attacks (≥2 attacks per year) 1
  • Chronic kidney disease stage 2 or worse 1
  • History of urolithiasis 1

Urate-Lowering Therapy Approach

First-Line Therapy

• Allopurinol is the preferred first-line ULT, including for patients with moderate-to-severe chronic kidney disease 1, 2
• Start at a low dose (100 mg daily or 50 mg daily in stage 4 or worse CKD) 1, 3
• Increase dose by 100 mg every 2-4 weeks until target serum urate is achieved 1, 3
• Maximum recommended dose is 800 mg daily, which may be administered in divided doses 3

Alternative First-Line Therapy

• Febuxostat can be used when allopurinol is not tolerated or contraindicated 4
• Febuxostat 80 mg/day is more effective than allopurinol 300 mg/day at lowering serum urate levels 4, 5
• Consider cardiovascular safety concerns with febuxostat, which has shown higher risk of cardiovascular-related death compared to allopurinol 4

Second-Line Therapy

• Uricosuric agents (probenecid, sulphinpyrazone) can be used as alternatives in patients with normal renal function 1
• Benzbromarone can be used in patients with mild to moderate renal insufficiency but carries a small risk of hepatotoxicity 1, 6

Treat-to-Target Strategy

• Implement a treat-to-target strategy with ULT dose titration guided by serial serum urate measurements 1
• Target serum urate level should be <6 mg/dL for all patients receiving ULT 1
• Serum urate lowering below 5 mg/dL may be needed to improve gout signs and symptoms in severe cases 1
• ULT titration should occur over a reasonable time frame (weeks to months, not years) to prevent "treatment inertia" 1
• Continue ULT indefinitely to maintain target serum urate levels 1

Flare Prophylaxis During ULT Initiation

• Concomitant anti-inflammatory prophylaxis for 3-6 months when initiating ULT is strongly recommended 1
• Options for prophylaxis include:
  • Colchicine (0.5-1 mg daily, adjusted for renal function) 1, 7
  • Low-dose NSAIDs with gastroprotection if indicated 1, 7
• Continue prophylaxis for at least 3-6 months after achieving target serum urate for patients without tophi 2
• For patients with tophi, continue prophylaxis for 6 months after achieving target serum urate and resolution of tophi 2

Management of Acute Flares During Chronic Gout Treatment

• First-line options for acute flare treatment include:
  • Colchicine (most effective when started within 12 hours of symptom onset) 1, 2
  • NSAIDs at full anti-inflammatory doses 1, 2
  • Corticosteroids (oral, intraarticular, or intramuscular) 1, 2
• ULT should not be discontinued during acute flares 1, 8
• ULT can be initiated during a flare if adequate anti-inflammatory treatment is provided 1

Lifestyle Modifications

• Weight loss is recommended for obese patients 2
• Limit consumption of purine-rich foods (organ meats, shellfish) 1, 9
• Avoid alcoholic drinks, especially beer 1, 9
• Avoid beverages sweetened with high-fructose corn syrup 9
• Encourage consumption of vegetables and low-fat or nonfat dairy products 9
• Consider discontinuing diuretics if possible, as loop and thiazide diuretics can increase uric acid levels 1, 9

Monitoring and Follow-up

• Regular monitoring of serum urate levels to ensure target is maintained 1, 7
• Monitor for ULT side effects, particularly during dose escalation 3
• Consider delivery of an augmented protocol of ULT management by non-physician providers (nurses, pharmacists) to optimize the treat-to-target strategy 1

Common Pitfalls to Avoid

• Starting with too high a dose of allopurinol, which increases risk of hypersensitivity reactions 3
• Failure to provide prophylaxis when initiating ULT, leading to increased flare frequency and reduced medication adherence 7
• Fixed-dose ULT strategy rather than treat-to-target approach 1
• Discontinuing ULT during acute flares, which can worsen long-term outcomes 1, 8
• Inadequate duration of therapy (ULT should be continued indefinitely in most cases) 1