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