Educating patients about their disease and the lifestyle changes needed is vital. “Patients need to recognize that gout is caused by a body excess of uric acid and that targeting this problem with nonpharmacologic and in many cases pharmacologic urate-lowering therapy is the only approach that will have a ‘curative’ impact on their condition,” Dr. Terkeltaub says.
Other Recommendations in Part I
- Recommendations are given regarding the starting dose of allopurinol. This starting dose should not exceed 100 mg per day; an even lower dose than that can be used in patients with moderate to severe chronic kidney disease. Gradual upward titration of the maintenance dose can exceed 300 mg daily.
- If the serum urate target is not achieved with one XOI, combination therapy with one XOI and one uricosuric agent is appropriate.
- Novel recommendations are included on pharmacogenetics for allopurinol risk management strategies.
- Ultrasound can be helpful to identify subclinical findings of gout.
Acute Gouty Attacks: Part II
Part II of the guidelines, which focuses on therapy and antiinflammatory prophylaxis of acute gouty arthritis, highlights the need to treat an acute attack within 24 hours of onset and the importance of continuing urate-lowering therapy without interruption during an attack.
As in Part I of the guidelines, Part II also includes case scenarios. These are differentiated by the severity of acute gout based on self-reported worst pain on a 0–10 visual analog scale, with pain less than or equal to 4 considered mild, 5–6 considered moderate, and greater than or equal to 7 considered severe. The case scenarios are also further divided based on the duration of the acute gout attack (<12 hours after attack onset, 12 to 36 hours after onset, or >36 hours after attack onset), and the number and size of the involved joints.
Dr. Fitzgerald notes that the guidelines make clear that urate-lowering therapy can be initiated during an acute attack once the patient has been placed on appropriate antiinflammatory agents, such as nonsteroidal antiinflammatory drugs (NSAIDs), systemic corticosteroids, or oral colchicine. NSAIDs can be given at full dosing to treat acute pain and/or acute gout, and prednisone is recommended at a starting dose of at least 30 mg daily. According to the guidelines, oral colchicine is one of the appropriate options for treatment of acute gout, but only where symptom onset was no more than 36 hours prior to initiation of therapy.
Combination therapy is recommended as an option to consider, particularly when acute gout attack is characterized as severe pain in a polyarticular attack. Algorithms are included in the guidelines that recommend the sequence of therapies that should be used to treat an acute gouty attack, with both monotherapy and combination therapy options.
