GOUT
This common, painful condition can be relatively easily treated with a variety of treatment options for the acute immediate disease presentation as well as long-term control.
My approach is to get over the immediate gout attack with appropriate anti-inflammatory treatment. In my experience, the most effective for the majority of patients is colchicine (brand names are Colcrys or Mitigare), which is very well tolerated provided it is correctly dosed. A little know secret is that colchicine, in addition to its direct effect on cells called neutrophils, which are involved in inflammation, also reduces superoxides production that is triggered by the effects of excess uric acid crystals in and around the affected joint.
Colchicine is preferred over Non-steroidal anti-inflammatory drugs, as it can be safely used in many older patients including those who have almost any degree of chronic kidney disease (with some dose adjustment). The drug is also beneficial in preventing relapse or post-acute gout flares when used over a period of up to 6-8 months in patients who are at higher risk. Those at risk include patients with frequent attacks, gout with uric acid deposits known as tophi, chronic kidney disease, obesity or other metabolic disease or metabolic syndrome, high triglycerides, diabetics, etc.
Alcohol should be avoided or intake significantly reduced.
Other anti-inflammatories that may be offered include most NSAIDs or Celebrex. If colchicine is for some reason not tolerated or contraindicated and there is a risk of gastrointestinal disturbance, liver or kidney disease, I may choose to treat with a steroid dose-pack or inject the acutely inflamed joint (named podagra if it involves the 1st toe joint), with a corticosteroid injection with a local anesthetic. NSAID treatment may also be offered in lower dosing over longer periods as required to avoid break-through gout attacks while preventative treatment is initiated.
Long-term treatment must include uric acid lowering which is the driver of this condition. This is usually achieved with either allopurinol or febuxostat (Uloric®). The usual starting dose is 100mg/day with dose increase adjustments according to the patient’s uric acid lowering response. Patients at increased risk of allopurinol hypersensitivity or intolerance include Asians of Han dynasty ancestry, including people of Native Hawaiian/Pacific Islander ethnicity and African-Americans and older patients or presence of chronic kidney disease. They should also be offered screening with a test called HLA-B*5801.
Uric acid-lowering (usually with allopurinol or febuxostat) aka urate-lowering, is required for patients who have 2 or more attacks annually, have 1 or more deposits or urate salts known as tophi, or evidence of joint damage on any imaging study such as an x-ray, ultrasound or MRI.
I also provide opportunities for discussion of dietary and traditional or alternative medicine approaches to urate-lowering and always encourage moderation or alterations of choice of alcohol intake.
Long-term, most patients will achieve complete control of their gout provided good dietary measures, adjustment or cessation of alcohol intake & drug compliance can be achieved. Occasionally, you may require additional medications to lower urate including the newer oral agent lesinurad/Zurampic (used in combination with either allopurinol or febuxostat/Uloric or intravenous pegloticase/Krystexxa for chronic gout refractory to conventional therapy
