After an acute attack some patients remain at high risk of another attack for several weeks during the intercritical period. Such patients include those with kidney insufficiency or those with congestive heart failure who are on diuretics. Colchicine or NSAIDs may be used for 1 to 2 months or longer to prevent another attack.
Long-term Prevention of Attacks
The cause of gout is hyperuricemia. Lifestyle changes should be recommended for all patients with gout, including weight loss if obese, dietary changes, and reducing alcohol intake. If the uric acid remains elevated in spite of these recommendations, medicine that lowers uric acid level in the blood or that block uric acid production to prevent gout attacks and other complications is usually prescribed.
Hyperuricemia that causes no symptoms may not need to be treated with medicine. Asymptomatic hyperuricemia often does not lead to gout or other health problems.
Before treatment, a 24-hour urine collection sample may be ordered for patients with frequent gout attacks. This is to determine whether they are over-producers or under-excreters of uric acid.
Low doses of NSAIDs or colchicine are used during several months after starting urate lowering medicine to prevent gout attacks.
Long-term treatment of hyperuricemia is now recommended for people who have had an attack of gout and any of the following:
- Tophi on exam or by imaging
- More than 2 attacks per year
- History of kidney stones
- Chronic kidney disease of any sort
There are several reasons people with gout and kidney disease should be started on urate lowering medications with only 1 attack of gout. They usually have hyperuricemia due to the kidney disease, treating acute gout is more difficult with kidney disease, and medicines such as allopurinol may protect the kidneys from worsening kidney disease.
First line recommended therapies to lower uric acid include allopurinol or febuxostat.
Allopurinol. Allopurinol decreases uric acid production by blocking an enzyme called xanthine oxidase. It is the drug most often used in long-term gout treatment for older patients, in patients with kidney disease, and those who overproduce uric acid.
When it is first started, allopurinol can trigger further attacks of gout. Therefore, a low dose is used first, and during the first months or longer, the patient also takes an NSAID or colchicine to reduce that possibility. Allopurinol is generally well tolerated but may cause side effects in some people, especially people of Chinese, Thai, or Korean heritage. A gene test called HLA B-5801 is recommended in such individuals before starting allopurinol.
Allopurinol has positive effects on hypertension, heart, and kidney disease, so it may be better than other medicines for patients with both gout and these conditions. Possible interactions with other medicines and allopurinol should be discussed with your physician before taking the medicine.
Febuxostat. Febuxostat is a newer drug and is particularly useful for patients who are allergic to allopurinol. Like allopurinol, it blocks xanthine oxidase, and gout may flare up after starting the medication. The FDA continues monitoring this drug for hypersensitivity reactions. It is much more expensive than allopurinol.
Uricosurics. Uricosurics are alternative first-line therapies. These drugs prevent the kidney from reabsorbing uric acid, and therefore, increase the amount excreted in the urine. They may be used when the kidneys are not eliminating enough uric acid which is present in about 80% of gout cases. The doctor will check a 24 hour urine to diagnose this problem. These medicines are not used for patients with reduced kidney function, or those with tophaceous gout.
Other patients who may benefit from uricosurics include:
- Under 60 years of age
- Normal diets
- Normal kidney function
- No risk of kidney stones
NSAIDs, particularly aspirin and similar medicines, reduce the effectiveness of uricosurics. Patients taking uricosurics should avoid NSAIDs if possible.
Probenecid. Probenecid is an older medicine developed in the 50's, and the only uricosuric available in the United States. It may be useful in patients who cannot take other gout medications. It is generally well tolerated. New uricosuric medicines are being developed for gout and will most likely be available soon.
Pegloticase (Krystexxa, formerly Puricase). Pegloticase is an enzyme that breaks down uric acid so it is removed through the urine. Pegloticase injections are given intravenously every two weeks and are reserved for patients with severe chronic gout who have not been helped by first-line treatments. Mild to severe reactions are possible. The FDA recommends that an antihistamine and corticosteroid be given prior to the injection to prevent reactions and that other urate lowering medicines be stopped. Several side effects are possible, some of which can be severe. It has not been tested in patients with heart failure.
Information About Medicines for Gout
Starting medicines which lower uric acid can set off an attack of gout. You should work with your doctor to learn which medicines and dosages may cause gout flare-ups. In general, it is best to increase the dose slowly over many weeks. Also, you may need a medicine such as colchicine to prevent gout flares for the first several months after starting the urate lowering medicine. Your uric acid should be lowered to less than 6.0 mg/dL, and sometimes less than 5.0 mg/dL. Gout medications may interact with other drugs. Most people with gout will need to take the urate lowering medicine for the rest of their life.
People with gout have a high risk of high blood pressure (hypertension). Some medicines for hypertension, such as thiazide diuretics, can increase the risk of gout attacks. Other medicines, such as calcium channel blockers, may have beneficial effects on both high blood pressure and gout.
Surgery. Large tophi that are draining, infected, or interfering with the movement of joints may need to be surgically removed. Surgery may not be suitable for persons with other medical conditions such as infection. In most cases, measures such as taking medicines that lower uric acid should reduce the need for surgery.
Other types of surgeries are available to relieve joint pain and improve joint function. In some cases joint replacement is needed.
Rest and protecting the affected joint with a splint can also promote recovery. Applying ice packs during an acute attack can help relieve symptoms.