Gout is the commonest crystal arthropathy that has seen a dramatic increase in its prevalence in the last decade.

 

 

 

 

Gout often presents as severe monoarthritis of acute onset in lower limb joints such as the first metatarsophalangeal (MTP) joint or ankle.

Though the ways for its management and prophylaxis have improved remarkably in recent times it is still considered as an easily misdiagnosed as well as mismanaged arthritis. The patients are often treated inadequately and risk factors for their disease are not well explored in daily practice. This is mainly because gout is handled haphazardly by different category of doctors. Strangely it has been seen that some biochemists, gynaecologists, and even anatomists are treating gout here and there. Moreover, many physicians and basic doctors are not well-trained to manage gout properly.

There is very little awareness among patients that gout should be treated by “Rheumatologists”.

So, training of physicians, orthopedician, is an urgent need of the time along with the training and education of the patients.3

Moreover, there is mounting evidence that confirms a clear association between gout and cardiovascular events, kidney failure and mortality. This has heightened the realization that gout should never be neglected and should be treated properly.2

---

The incidence of gout in developing countries like India is on rising. Although there is a lack of data about its prevalence its rise can be attributed to factors like rapid urbanization and lifestyle changes that lead to reduced physical activity, obesity, protein-rich diet, alcoholism, etc. Studies conducted in India suggest definite male preponderance, monoarticular (ankle joint being the commonest) initial presentation and first affected joint being metatarsophalangeal joint. Most patients are under-secretors of uric acid with higher incidence of renal calculi. Females have a later onset, longer duration, and higher uric acid levels when compared to males.

Acute Gout Management - India

The main aim of treatment in acute gout cases is relief from pain and inflammation. The choice of drug involves non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and glucocorticoids. Generally, a physician prefers NSAIDs when the diagnosis is confirmed, whereas colchicine is used when diagnosis of acute gout is not sure. IL-1 inhibitors like anakinra, rilonacept or canakinumab may be used in patients unresponsive to NSAID or colchicines. Urate lowering therapy (ULT) is generally initiated when the patient is stable after 2-4 weeks and continued lifelong.

The uric acid level is targeted at <6 mg/dL in general and <5 mg/dL in patients with tophi.

Even though there has been continuous improvement in the management of gout, its diagnosis and management remains suboptimal. This situation prompted the elaboration of the European League Against Rheumatism (EULAR) recommendations for the management of gout based on a systematic literature review (SLR) and expert opinion.

EULAR recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.

---

Overarching Principles of Gout Treatment

• Patients should receive complete information about gout including its pathophysiology, treatment options, comorbidities, general medical management of acute attack, and the lifelong need to reduce serum uric acid (SUA).
• Patients should be regularly counseled on lifestyle modifications, including regular exercise, weight loss, alcohol avoidance, and dietary recommendations.
• Patient should be screened for known disease comorbidities, including renal impairment, coronary artery disease, stroke, dyslipidemia, diabetes, and peripheral arterial disease

---

EULAR recommendations summary 

Acute flares

Treat as soon as possible

Inform and educate patient to self-medicate at the first warning symptoms

Choose drug based upon the following:

• Presence of contraindications
• Patient’s previous experience with treatments
• Time of initiation after flare onset
• Number and type of joint(s) involved

---

First-line recommendation for acute flares

• colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or
• NSAID (plus proton pump inhibitors if appropriate), oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) or
• articular aspiration and injection of corticosteroids

Avoid Colchicine and NSAIDs in patients with severe renal impairment.

No Colchicine to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporine or clarithromycin.

---

Frequent flares and contraindications to colchicine, NSAIDs and corticosteroid (oral and injectable)

Consider IL-1 blockers

No IL-1 blockers in current infection

Adjust ULT (Urate-lowering therapy) to achieve the uricaemia target

---

 Recommended prophylaxis during the first 6 months of ULT

Colchicine 0.5–1 mg/day (reduce in patients with renal impairment)

Avoid co-prescription of colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors

Consider NSAID at low dose if not contraindicated and colchicine is not tolerated or is contraindicated

Inform patient about potential neurotoxicity and/or muscular toxicity with prophylactic colchicine in cases of renal impairment or statin treatment

---

 ULT for gout

ULT is indicated in all patients with recurrent flares, tophi, urate arthropathy and/or renal stones.

Initiation of ULT is recommended in following:

• first diagnosis in patients presenting at a young age (<40 years) or with a very high SUA level (>8.0 mg/dL; 480 mmol/L) and/or
• comorbidities (renal impairment, hypertension, ischaemic heart disease, heart failure)

---

SUA level for patients on ULT

Monitor and maintain SUA level to <6 mg/dL (360 mmol/L)

A lower SUA target (<5 mg/dL; 300 mmol/L) to facilitate faster dissolution of crystals is recommended for patients with severe gout (tophi, chronic arthropathy, frequent attacks) until total crystal dissolution and resolution of gout.

SUA level <3 mg/dL is not recommended in the long term.

---

ULT dose & titration

Start ULTs at a low dose and then titrate upwards until the SUA target is reached.

---

Recommendation for Allopurinol

Allopurinol is recommended for first-line ULT in patients with normal kidney function, starting at a low dose (100 mg/day) and increasing by 100 mg increments every 2–4 weeks if required, to reach the uricaemia target.

Switch allopurinol to febuxostat or a uricosuric or combination if the SUA target cannot be reached by an appropriate dose of allopurinol or if allopurinol is not tolerated.

Dose adjustment of allopurinol

• Adjust maximum dose of allopurinol to creatinine clearance in patients with renal impairment.
• Switch to febuxostat or given benzbromarone with or without allopurinol if SUA target cannot be achieved at above dose, except in patients with estimated glomerular filtration rate <30 mL/min.

---

Pegloticase indication

It is indicated in patients with crystal-proven, severe debilitating chronic tophaceous gout and poor quality of life, in whom the SUA target cannot be reached with any other available drug at the maximal dosage (including combinations).

---

Gout in a patient receiving loop or thiazide diuretics

Substitute diuretic if possible;

• consider losartan or calcium channel blockers for hypertension
• consider a statin or fenofibrate for hyperlipidaemia