Summary

While considering treatment of gout, doctors will have to keep in mind the 3 facets:

• Treatment of an acute attack
• Prevention of further attacks
• Treatment of hyperuricemia

Until recently, allopurinol was the only antihyperuricaemic available for the treatment of gout. Now, there are several medications available and new ones in the horizon. However, their usage needs to be guided strictly. Using certain combinations can prove to be dangerous and doctors need to consider other comorbidities too such as renal or cardiac diseases. 

Overall, management involves two steps- treatment of an acute attack and prophylaxis to prevent future attacks. Apart from this there are drugs to treat tophaceous gout and treatment-refractory gout (TFG).

Treatment of hyperuricaemia

1. The duration of treatment while using urate-lowering therapies is lifelong. Target of treatment in gout is serum uric acid (sUA) levels of <5.5 mg/dl. Therefore, allopurinol should not be started during an acute attack of gout as it may precipitate another attack or prolong the duration.
2. Allopurinol should also not be discontinued. Patients already on allopurinol should continue the drug. Restricting allopurinol dose to 300 mg/day sub-optimally controls gout in a substantial number of patients. The dose ranges from 100-800 mg per day.
3. Colchicine in lower doses is equally effective but far better tolerated. As of now, the main role for colchicine is as prophylaxis for recurrent attacks (>2-3/year)
4. It is not recommended to combine allopurinol with febuxostat. Uricosurics can be combined with xanthine oxidase inhibitors.
5. Uricosuric drugs include the urate transporter 1 (URAT1) inhibitors benzbromarone and probenecid.

Treatment of an acute attack:

Firstly, physicians should remember that treating acute attacks in gout only is like treating the tip of an iceberg.

1. During an acute attack, the treatment of choice should be NSAIDs. In case NSAIDs are contraindicated, colchicine or corticosteroids may be used. Intraarticular corticosteroids are extremely effective in acute gout.
2. Oral prednisolone 20-40 mg daily tapered over 2 weeks or intra-muscular methyl prednisolone 40-120 mg may be used.

Therapy considerations in special cases

It is important to remember that Febuxostat, the preferred urate-lowering therapy in renal insufficiency is metabolised primarily by the liver. Therefore, allopurinol should be preferred over febuxostat in patients with liver disease. However, the dose of allopurinol should be reduced in case of renal insufficiency.

In transplant patients, it is vital to consider allopurinol-azathioprine interaction. Allopurinol inhibits xanthine oxidase, the enzyme which metabolises azathioprine. This can lead to marked reduction in the WBC count.

Prophylactic therapy to prevent further attacks

Colchicine can be combined with allopurinol as prophylaxis therapy. Patients with recurrent attacks (>3 per year) can be advised colchicine (0.5 mg twice, daily) for 6 to 12 months in addition to allopurinol.

Tophaceous gout treatment

1. Uricase enzyme pegloticase can be used as IV infusion every 2 weeks at a dose of 8 mg
2. Lesinurad, a recently approved, selective uric acid reabsorption inhibitor can be used at a dose of 200 mg, once daily in combination with XO inhibitors.