From the Guidelines
The treatment for chronic gouty arthritis focuses on lowering uric acid levels to prevent future attacks and joint damage, with first-line therapy typically involving xanthine oxidase inhibitors such as allopurinol or febuxostat, and a target serum uric acid level below 6mg/dL. The American College of Rheumatology guideline for the management of gout recommends initiation of urate-lowering therapy (ULT) for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares, with allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD) 1. When initiating ULT, concomitant anti-inflammatory prophylaxis therapy for a duration of at least 3–6 months is strongly recommended to prevent flares that commonly occur as uric acid levels change 1. Lifestyle modifications are also important, including weight loss if overweight, limiting alcohol intake (especially beer), avoiding high-purine foods like organ meats and shellfish, and staying well-hydrated. Treatment is typically lifelong as discontinuation often leads to recurrence of gout attacks. Regular monitoring of uric acid levels and kidney function is necessary to ensure treatment effectiveness and safety.
Some key points to consider in the management of chronic gouty arthritis include:
- Using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (≤40 mg/day) 1
- Implementing a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl 1
- Considering combination oral ULT, with one XOI agent and one uricosuric agent, when the serum urate target has not been met by appropriate dosing of an XOI 1
- Monitoring for potential drug interactions and effects of co-morbidities, such as diabetes, and renal, cardiac, gastrointestinal, and hepatic disease 1
Overall, the goal of treatment for chronic gouty arthritis is to reduce uric acid levels, prevent future attacks, and improve quality of life, with a focus on individualized patient care and regular monitoring to ensure treatment effectiveness and safety 1.
From the FDA Drug Label
KRYSTEXXA® (pegloticase) is a PEGylated uric acid specific enzyme indicated for the treatment of chronic gout in adult patients refractory to conventional therapy The recommended dose and regimen of KRYSTEXXA for adult patients is 8 mg (uricase protein) given as an intravenous infusion every two weeks. Probenecid tablets are indicated for the treatment of the hyperuricemia associated with gout and gouty arthritis.
The treatment for chronic gouty arthritis includes:
- Pegloticase (IV): 8 mg given as an intravenous infusion every two weeks for adult patients refractory to conventional therapy 2
- Probenecid (PO): for the treatment of hyperuricemia associated with gout and gouty arthritis 3
- Colchicine (PO): for prophylaxis and treatment of gout flares 4
From the Research
Treatment Options for Chronic Gouty Arthritis
The treatment for chronic gouty arthritis involves a combination of lifestyle modifications, pharmacological interventions, and patient education.
- Lifestyle modifications form a part of gout prevention 5.
- First-line agents for gout flares include NSAIDs, colchicine, and glucocorticoids 5, 6, 7, 8.
- Urate-lowering therapies, such as allopurinol and febuxostat, aim to prevent gout flares and reduce serum uric acid levels 5, 6, 9, 7, 8.
- IL-1β antagonists are highly effective for arresting flares but are considered salvage therapies due to their cost-effectiveness 5.
- Novel uricosurics, such as verinurad and arhalofenate, are emerging therapies with future promise 5.
- Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity can threaten sustained urate lowering responses 5, 9, 8.
Pharmacological Interventions
Pharmacological interventions play a crucial role in the management of chronic gouty arthritis.
- Colchicine is the preferred specific flare treatment, but caution is necessary in patients with kidney disease, hepatic dysfunction, or interacting comedications 6.
- NSAIDs and prednisone are valuable alternatives for flare treatment 6, 7, 8.
- Interleukin-1 blockers offer a quick resolution of flares and may be an option in patients with chronic gout and severe kidney disease 6, 7.
- Xanthinoxidase inhibitors (XOI) are the mainstay of urate-lowering therapy, with allopurinol being the preferred XOI 6, 9, 7, 8.
- Uricosuric drugs, such as probenecid, are recommended in patients with sufficient renal function in whom treatment goals cannot be reached with XOI 6, 9, 8.
Patient Education and Adherence
Patient education and adherence to therapy are key points in the optimal management of gout.
- Adherence can be monitored in part by continuing, regular assessment of the serum uric acid level 9.
- Patient education is essential to ameliorate compliance and achieve treatment success 6.
- Comorbidities, such as metabolic syndrome, cardiovascular and kidney disease, are often found in gout patients and require consideration in treatment planning 6, 7.