Monday, May 18, 2015

Initiating Urate lowering Drugs in Gout

  • prolonged use of colchicine and NSAIDs may prevent recurrent episodes of gouty arthritis, BUT do not prevent the development of silent bony erosions and tophaceous deposits
  • effect of antihyperuricemic drugs in preventing functionally significant renal impairment in patients with gout has been considered but has not been established 
  • This may reflect uncertainty about whether hyperuricemia alone or hyperuricemia in patients with gout produces functionally significant renal disease.

Indications ( in patients with a history of gout ):
  • Frequent and disabling attacks of gouty arthritis
  • Clinical or radiographic signs of chronic gouty joint disease
  • Tophaceous deposits in soft tissues or subchondral bone
  • Gout with renal insufficiency
  • Recurrent uric acid nephrolithiasis despite treatment with hydration and urinary alkalinization
  • Urinary uric acid excretion exceeding 1100 mg/day (6.5 mmol), when determined in men less than 25 years of age or in premenopausal women
  • *Precise definitions of frequent or disabling attacks are not strictly established.More than two or three attacks annually are often quoted as an indication for urate-lowering treatment.
  • *However, a lower threshold for treatment may be considered after discussion with the patient if attacks significantly affect QOL

Initiation & Duration
  • urate-lowering therapy should not be initiated until after an acute gout flare has resolved, and we wait at least two weeks after an acute flare has subsided to initiate urate-lowering medication.
  • acute urate-lowering can precipitate a gout attack and upon a concern that initiation of urate-lowering therapy during an acute attack may worsen or prolong the inflammatory arthritis
  • Once the decision is made to begin therapy to lower serum urate, the duration of therapy is indefinite and should be continuous to remain effective
  • Monitoring
  • We suggest that antihyperuricemic therapy be titrated to a dose that results in maintenance of a serum urate in the range <6 mg/dL (<357micromol/L) (Grade 2C). Lowering the serum uric acid slowly (no more than 1 to 2 mg/dL/month) is suggested (Grade 2C) in an effort to minimize the occurrence of gout flares

Monitoring
  • serum urate concentration within two to four weeks of a dose adjustment, with confirmation three months later. Once goal values are confirmed, measurement every six months for the next year and then annually

Choice of Agent

Prophylaxis
  • Recommend low-dose prophylactic colchicine (0.6 mg once or twice daily for patients with normal renal and hepatic function) during the initiation of antihyperuricemic therapy (Grade 1A). A NSAID is an alternative, although to date unvalidated, approach to flare prophylaxis in patients who cannot tolerate colchicine (Grade 2C).
  • We suggest that colchicine be continued for six months after normal serum urate values have been obtained in patients without tophi (Grade 2C).


 References:
1. www.uptodate.com

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