What are the recommendations for managing gout in Malaysia?

Management of Gout in Malaysia

Follow the 2017 EULAR evidence-based recommendations as the foundation for gout management in Malaysia, emphasizing patient education, treat-to-target urate lowering, and early aggressive treatment of acute flares. 1

Core Management Principles

Patient Education (Critical First Step)

• Every patient must be fully informed about gout pathophysiology, the existence of curative treatments, associated comorbidities, and the need for lifelong serum uric acid (SUA) lowering below target levels. 1
• Education increases adherence to urate-lowering therapy (ULT) to 92% at 12 months, making this the single most important intervention. 1
• Patients should be educated to self-medicate acute flares at first warning symptoms. 1

Lifestyle Modifications (Essential Adjunct)

• Weight loss if obese, avoidance of alcohol (especially beer and spirits), sugar-sweetened drinks, heavy meals, and excessive meat/seafood intake. 1
• Encourage low-fat dairy products and regular exercise. 1
• These modifications are efficacious in reducing SUA levels and preventing attacks. 1

Comorbidity Screening (Mandatory)

• Systematically screen for cardiovascular risk factors including renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidemia, hypertension, diabetes, and smoking. 1
• Address these as an integral part of gout management. 1

Acute Gout Management

First-Line Treatment Options

Treat acute flares as early as possible with one of the following: 1

• Colchicine: 1 mg loading dose followed by 0.5 mg one hour later (within 12 hours of flare onset), then 0.5 mg daily. 1

  • Avoid in severe renal impairment. 1
  • Do NOT give with strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin). 1

• NSAIDs: Non-selective NSAIDs or COX-2 inhibitors with proton pump inhibitors if appropriate. 1

  • Avoid in severe renal impairment. 1

• Corticosteroids: Oral prednisolone 30-35 mg/day for 3-5 days, or intra-articular injection after joint aspiration. 1

Critical Pitfall in Malaysia

A 2009 Malaysian survey found 10.2% of doctors inappropriately use allopurinol during acute attacks, and 50% stop allopurinol during flares—both practices are incorrect. 2 Do NOT start or stop ULT during an acute attack; continue existing ULT unchanged. 1

Alternative for Refractory Cases

• IL-1 blockers for patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids. 1
• Current infection is a contraindication. 1

Chronic Gout Management: Urate-Lowering Therapy

Indications for ULT

ULT should be considered and discussed with every patient from first presentation. 1 It is specifically indicated in: 1

• Recurrent acute attacks
• Tophi
• Urate arthropathy
• Radiographic changes of gout
• Renal stones
• Young age (<40 years)
• Very high SUA (>8 mg/dL or 480 μmol/L)

Treatment Target

Maintain SUA <6 mg/dL (360 μmol/L) lifelong; for severe gout (tophi, chronic arthropathy, frequent attacks), target <5 mg/dL (300 μmol/L) until crystal dissolution. 1

A 2009 Malaysian survey revealed only 10.9% of doctors target low-normal urate levels, with 45.3% accepting "anywhere within normal range"—this is inadequate. 2

First-Line ULT: Allopurinol

Start allopurinol at 100 mg daily and increase by 100 mg every 2-4 weeks until SUA target is achieved. 1, 3

• Maximum dose: 800 mg daily (in divided doses if >300 mg). 3
• In renal impairment: 1
  • Creatinine clearance 10-20 mL/min: 200 mg daily maximum
  • Creatinine clearance <10 mL/min: 100 mg daily maximum
  • Can be used with close monitoring for adverse events 1

Second-Line Options

If allopurinol fails to achieve target or causes toxicity: 1

• Febuxostat: Can be used without dose adjustment in renal impairment (except eGFR <30 mL/min). 1
• Uricosurics (benzbromarone, probenecid): Alternative in normal renal function without urolithiasis. 1
  • Benzbromarone is more effective than allopurinol but may be hepatotoxic. 1
• Combination therapy: Allopurinol plus uricosuric if monotherapy inadequate. 1

Last Resort

Pegloticase: Only for crystal-proven severe debilitating chronic tophaceous gout when all other drugs at maximal doses (including combinations) have failed. 1

Flare Prophylaxis During ULT Initiation

Prophylaxis is mandatory for the first 6 months of ULT. 1

• First choice: Colchicine 0.5-1 mg daily (reduce dose in renal impairment). 1

  • Be aware of neurotoxicity/muscular toxicity risk with renal impairment or statin co-prescription. 1
  • Avoid with P-glycoprotein/CYP3A4 inhibitors. 1

• Alternative: Low-dose NSAIDs if colchicine contraindicated or not tolerated. 1

Timing of ULT Initiation

Start ULT close to the time of first diagnosis, ideally after the acute attack resolves (median 14 days in Malaysian practice). 1, 2 Do NOT delay ULT initiation unnecessarily. 1

Special Considerations

Diuretic-Associated Gout

When gout occurs in patients on loop or thiazide diuretics, substitute the diuretic if possible. 1

• For hypertension: Consider losartan or calcium channel blockers. 1
• For hyperlipidemia: Consider statin or fenofibrate. 1

Tophaceous Gout

Treat medically by achieving sustained SUA reduction, preferably <5 mg/dL (300 μmol/L). 1

• Surgery only indicated for specific complications (nerve compression, joint destruction, infection, mechanical problems). 1

Asymptomatic Hyperuricemia

Do NOT treat asymptomatic hyperuricemia with ULT. 1 Only 15% of Malaysian doctors appropriately avoid treating this condition. 2

Malaysian Context-Specific Issues

The 2009 Malaysian survey identified critical gaps: 2

• Corticosteroids underutilized (>90% never use)
• Inappropriate allopurinol use during acute attacks (10.2%)
• Stopping allopurinol during flares (50%)
• Inadequate urate targeting
• Starting ULT during acute attacks (4.7%)

These practices must be corrected to align with international evidence-based guidelines. 1, 2