The Treatment of Gout

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Medical Education Library

The Treatment of Gout

June 2012 · Vol. 61, No. 06 Suppl: S11-S15

References

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Colchicine. Much of the recent clinical investigation regarding pharmacologic treatment of an acute gout attack has involved colchicine. To overcome the limitations of the standard dose-to-toxicity regimen of colchicine, a low-dose regimen of colchicine (1.2 mg followed by 0.6 mg 1 hour later) was investigated and subsequently approved by the US Food and Drug Administration (FDA).²⁴

Approval was based on a randomized, double-blind comparison with high-dose colchicine (1.2 mg followed by 0.6 mg every hour for 6 hours) and placebo in 184 patients with an acute gout attack.²⁵ The primary endpoint, a 50% or greater reduction in pain at 24 hours without the use of rescue medication, was reached in 28 of 74 patients (38%) in the low-dose group, 17 of 52 patients (33%) in the high-dose group, and 9 of 58 patients (16%) in the placebo group (P = .005 and P = .034, respectively, versus placebo). An AE occurred in 36.5% and 76.9% of study participants in the low-dose and high-dose colchicine groups, respectively, and in 27.1% of participants in the placebo group. Gastrointestinal AEs (eg, diarrhea, nausea, and vomiting) were less common in the low-dose colchicine group ( FIGURE ). All AEs in the low-dose group were mild to moderate in intensity, while 10 of 52 patients (19.2%) in the high-dose group had an AE of severe intensity. Concomitant use of numerous drugs can increase the concentration of colchicine. Examples include atorvastatin, fluvastatin, pravastatin, simvastatin, fibrates, gemfibrozil, digoxin, clarithromycin, erythromycin, fluconazole, itraconazole, ketoconazole, protease inhibitors, diltiazem, verapamil, and cyclosporine, as well as grapefruit juice.²⁶

FIGURE

Frequency of selected adverse events occurring over 24 hours with low-dose vs high-dose colchicine²⁵

Treatment plan:

For an acute gout attack: Begin low-dose colchicine therapy at the onset of an attack (1.2 mg followed by 0.6 mg 1 hour later)
For an acute attack/chronic gout: Implement the care plan ( TABLE )²⁷
Referral to a dietitian for guidance on foods and beverages to avoid (eg, seafood, red meat, and beer)

TABLE

Care plan for a patient with gout²⁷

	Acute flare	Chronic gout
Goals	To recognize and manage acute flare To treat pain as quickly as possible	To prevent future flares To slow and reverse joint and soft tissue damage
Educational points	Promote patient self-management for very early recognition and treatment of acute flare symptoms Provide an action plan and a means to record flare number, duration, and intensity as well as medication for treating acute flares at home Provide guidance on when to call the clinic during a flare and what to do if acute treatment is not effective Provide guidance on the most likely adverse drug reactions	Discuss the silent phases of the disease (between flares)and the importance of monitoring sUA levels and continued adherence with ULT Inform patients that initiation of ULT may increase the early risk for acute flare, and provide flare prophylaxis for at least 6 months Remind patients that acute flares during treatment should be treated with anti-inflammatory medications but to continue ULT for long-term flare prevention Provide guidance on lifestyle modifications to reduce sUA levels Provide guidance on the most likely adverse drug reactions
sUA, serum uric acid; ULT, urate-lowering therapy. Source: Reproduced with permission. Becker MA, et al. J Fam Pract. 2010;59(6):S1-S8. Quadrant HealthCom Inc. Copyright 2010.

Urate-Lowering Therapy

Urate lowering therapy is indicated for most, but not all, patients with gout. ULT is generally not recommended for those who have suffered a single attack of gout and have no complications, since 40% of these patients will not experience another attack within a year. However, should a second attack occur within a year of the first attack, ULT is recommended. Some patients who have experienced a single attack may elect to initiate ULT after being educated about the risks of the disease and the risks and benefits of ULT.¹⁴ Patients who have had an attack of gout and also have a comorbidity (eg, visible gouty tophi, renal insufficiency, uric acid stones, or use of a diuretic for hypertension) should begin ULT, since the risk of further attacks is higher in these patients, and kidney or joint damage is more likely.¹⁷

Initiation of ULT should not occur until 1 to 2 weeks after an acute attack has resolved, since beginning ULT during an acute attack is thought to prolong the attack.¹⁷ Because gout is a chronic, largely self-managed disease, patient education is a cornerstone of successful long-term treatment. Implementation of a care plan for both an acute flare and chronic gout is recommended ( TABLE ).²⁷