Treatment Options for Gout

March 22, 2019

There are a number treatment options for acute gout flares, but only one mainstay to prevent flares. In this article, we review treatment options.

Because gout is an acute condition characterized by frequent flares, a variety of pharmacologic therapies are used for acute management while nonpharmacologic approaches and urate-lowering drugs are recommended for prevention of exacerbations. 

In the March 11 issue of The Medical Letter, researchers review treatment options.

TREATMENT FOR ACUTE FLARES

The three therapies recommended for treatment of acute flares include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or systemic corticosteroid treatments, which are among the least expensive drug therapies available. Interleukin-1 inhibitors such as canakinumab and are significantly more costly options, but may be used for patients who fail to respond to other therapies. For flares limited to only one or two joints, intra-articular corticosteroid injections may be used instead.

NSAIDs continue to be the mainstay of treatment―despite a high frequency of adverse events including dyspepsis, gastrointestinal ulceration, perforation, bleeding, and fluid retention leading to potential hypertension and renal failure, especially in older patients. Well-known risks of cardiovascular events such as myocardial infarction, stroke, and out-of-hospital cardiac arrest were associated with all NSAIDs, least of all with naproxen. It was recommended that the NSAID be started immediately upon onset of exacerbation, and continued until the symptoms resolve.

Colchicine was also deemed effective for acute management, and sometimes used for prevention of flares. The most common AEs included diarrhea, nausea, and vomiting and less commonly blood dyscrasia and neuromyopathy.

The report found that short courses of corticosteroids such as prednisone or methylprednisone demonstrated comparable efficacy to NSAIDs with fewer risks of serious adverse events, although fluid retention, hypertension, hyperglycemia, and central nervous system effects were reported, as well as flares and septic arthritis to the local injection site.

PREVENTION OF FLARES

Serum-urate lowering drugs such as allopurinol and febuxostat (where allopurinol is not tolerated) were recommended to reduce serum urate levels to at least <6.0 mg/dL with a goal of <5.0 mg/dL. Febuxostat carried higher risks of cardiovascular mortality than allopurinol.

Surprisingly, low-purine diets were found to have a far less significant impact on serum urate levels than previously believed. Weight loss and reduced alcohol intake were both recommended to prevent gout flares.

REFERENCE:

"Drugs for Gout," The Medical Letter on Drugs and Therapeutics. March 11, 2019, Issue 1567