treatment principles

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The principles of treatment in gout include:

  • acute flares of gout (1):

    • a non-steroidal anti-inflammatory drug (NSAID), colchicine or a short course of an oral corticosteroid for should be offered for first-line treatment of a gout flare, taking into account the person's comorbidities, co-prescriptions and preferences (In June 2022, this was an off-label use of oral corticosteroids)
    • consider adding a proton pump inhibitor for people with gout who are taking an NSAID to treat a gout flare
    • rest
    • increase fluid intake
    • if not subsiding in 12-24h, reconsider diagnosis.
    • consider an intra-articular or intramuscular corticosteroid injection to treat a gout flare if NSAIDs and colchicine are contraindicated, not tolerated or ineffective (in June 2022, this was an off-label use of corticosteroid injections)
    • advise people with gout that applying ice packs to the affected joint (cold therapy) in addition to taking prescribed medicine may help alleviate pain
    • follow-up after an acute flare
      • consider a follow-up appointment after a gout flare has settled to:
        • measure the serum urate level
        • provide information about gout and how to self-manage and reduce the risk of future flares
          • explain to people with gout that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels
            • advise them to follow a healthy, balanced diet
          • advise people with gout that excess body weight or obesity, or excessive alcohol consumption, may exacerbate gout flares and symptoms
        • assess lifestyle and comorbidities (including cardiovascular risk factors and CKD
        • review medications and discuss the risks and benefits of long-term ULT (urate lowering therapy)

Where possible, stop any exacerbating factors especially:

  • diuretics
  • excessive alcohol
  • usual management is to avoid purine-rich foods - NICE state that there is not enough evidence to show that any specific diet prevents flares or lowers serum urate levels (1)
    • the British Society of Rheumatology states (2):
      • "..In overweight patients, dietary modification to achieve a gradual reduction in body weight and subsequent maintenance should be encouraged. Diet and exercise should be discussed with all patients with gout, and a well-balanced diet low in fat and added sugars, and high in vegetables and fibre should be encouraged: sugar-sweetened soft drinks containing fructose should be avoided; excessive intake of alcoholic drinks and high purine foods should be avoided; and inclusion of skimmed milk and/or low fat yoghurt, soy beans and vegetable sources of protein, and cherries in the diet should be encouraged.."

  • long-term management of gout (1)
    • management of gout with urate-lowering therapies
      • offer ULT, using a treat-to-target strategy, to people who have:
        • multiple or troublesome flares
          • CKD stages 3 to 5 (glomerular filtration rate [GFR] categories G3 to G5)
          • diuretic therapy
          • tophi
          • chronic gouty arthritis
        • treat-to-target strategy
          • start with a low dose of ULT and use monthly serum urate levels to guide dose increases, as tolerated, until the target serum urate level is reached
          • aim for a target serum urate level below 360 micromol/litre (6 mg/dl)
          • consider a lower target serum urate level below 300 micromol/litre (5 mg/dl) for people with gout who:
            • have tophi or chronic gouty arthritis
            • continue to have ongoing frequent flares despite having a serum urate level below 360 micromol/litre (6 mg/dl)
      • discuss the option of ULT, using a treat-to-target strategy, with people who have had a first or subsequent gout flare who are not within the groups listed above
      • ensure people understand that ULT is usually continued after the target serum urate level is reached, and is typically a lifelong treatment
      • start ULT at least 2 to 4 weeks after a gout flare has settled. If flares are more frequent, ULT can be started during a flare*

    • * preventing gout flares when starting or titrating urate-lowering therapy
      • discuss with the person the benefits and risks of taking medicines to prevent gout flares when starting or titrating ULT
      • for people who choose to have treatment to prevent gout flares when starting or titrating ULT, offer colchicine while the target serum urate level is being reached. If colchicine is contraindicated, not tolerated or ineffective, consider a low-dose NSAID or low-dose oral corticosteroid (in June 2022, this was an off-label use of NSAIDs and oral corticosteroids)
      • consider adding a proton pump inhibitor for people with gout who are taking an NSAID or a corticosteroid to prevent gout flares when starting or titrating ULT. Take into account the person's individual risk factors for adverse events. In June 2022, this was an off-label use of NSAIDs and oral corticosteroids
  • consider annual monitoring of serum urate level in people with gout who are continuing ULT after reaching their target serum urate level

Prophylactic allopurinol and uricosurics:

  • are used for chronic gout only
  • are not effective in acute attack
  • are not used in an acute attack because they may prolong it indefinitely

Notes:

  • salicylates in low dose inhibit the renal tubular secretion of uric acid, whereas in higher doses they inhibit both secretion and reabsorption. With the high doses, interference with reabsorption predominates so that the net effect is uricosuric
    • the hyperuricaemic effect of small doses of salicylates is probably of little practical importance, although of course a careful drug history must always be taken for diagnostic purposes

Reference:

Last edited 06/2022 and last reviewed 06/2022

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