Dairy is of interest because it shows promise for reducing urate levels. “The more dairy you eat, the less gout you have,” Dr. Pillinger said. “And that holds after you adjust for meat consumption. It looks like something or other in dairy products drives the kidneys to excrete more uric acid.”
The baseline plan for managing established gout also includes indications for urate lowering. One key with urate-lowering therapy is to “treat to target,” Dr. Pillinger said. “The minimum serum urate target is less than 6.0 mg/dL, and serum urate lowering below 5 mg/dL may be needed to improve gout signs and symptoms.”
Use of an XOI, either allopurinol or febuxostat, is the recommended first-line therapy for urate lowering. An alternative first-line therapy, if at least one XOI is contraindicated or not tolerated, is the uricosuric probenecid. Probenecid is not considered a first-line therapy because it isn’t as effective as the XOIs, and there are limitations for using it, Dr. Pillinger noted.
“[Probenecid] doesn’t work well in people with any more than mild kidney disease because it relies on renal function to work,” Dr. Pillinger said. “Additionally, probenecid can raise the risk of kidney stones, particularly in patients with a history of them. Probenecid gets rid of urate by pushing it into the renal pelvis and into the urine,” he said. “You concentrate it in the kidney where it can precipitate. You have to drink a lot of water and may have to take medicine to keep the urine alkalotic.”
Prophylaxis
It’s extremely important to initiate prophylaxis along with urate-lowering therapy, Dr. Pillinger said. The ACR recommends low-dose colchicine (0.5–0.6 qD or BID) or low-dose NSAIDs (e.g., naproxen 250 BID) for first-line therapies and prednisone equal to or less than 10 mg/day as a second-line therapy.
Another important recommendation is to periodically assess for gout activity (e.g., acute attacks, persistent tophi, persistent chronic synovitis) during treatment. Prophylaxis should be continued if any disease activity is still present.
“Don’t stop the prophylaxis until the risk of attacks has gone away, and that’s characterized by getting rid not only of hyperuricemia, but also of the attacks themselves, as well as visible tophi and occult urate deposits, and then giving time to allow the dust to settle,” Dr. Pillinger said. “This will be four to five months minimum, and the maximum could be several years. This a very important recommendation.”
Kimberly J. Retzlaff is a medical journalist based in Denver.