Acute Treatment: NSAIDs are 1st-line (Indomethacin, Naproxen, and Ibuprofen all may be used to tx acute gout). Also and Colchicine. Corticosteroids are used when NSAIDs and Colchicine cant be used.
Colchicine inhibits microtubule formation reducing the inflammatory response to uric acid crystals. Almost universal S/E of colchicine include N/V/D.
Chronic Treatment: Allopurinol, Probenecid, Pegloticase, Febuxostat, and Colchicine.
Allopurinol is a xanthine oxidase inhibitor that prevents the production of uric acid.
*Don’t start allopurinol at the time of an acute attack of gout because it can lead to a transient increase in uric acid levels. However, people who were already on allopurinol should continue to take it at the same dose during an attack.
A) Medications for Treatment of Acute Gout
“Oral corticosteroids and nonsteroidal anti-inflammatory drugs are equally effective in the treatment of acute gout.” AAFP 2014
1. NSAIDs: NSAIDs are 1st-line treatment. All NSAIDs are equally effective.
E.g. Indomethacin 50 mg PO TID.
Watch out for s/e like GI bleeding and kidney injury.
2. Colchicine
Colchicine 1.2 mg initially, then 0.6 mg one hour later, then 0.6 to 1.2 mg per day.
G.I s/e are common. Don’t use in patients with kidney or liver insufficiency. Contraindicated in patients receiving Clarithromycin.
3. Corticosteroids: Preferred tx in patients in whom NSAIDs and colchicine are contraindicated (E.g. Patients with advanced kidney disease). Remember to taper over 10 to 14 days before discontinuing to avoid rebound flares.
Can give PO, IM, or Intra-articular (for single joint involvement).
Prednisone 40 mg PO QD x 4 days, then 20 mg x 4 days, then 10 mg x 4 days.
B) Medications for Prevention of Chronic Gout
Colchicine 0.6 to 1.2 mg QD. NB: May cause reversible axonal neuromyopathy; may increase the risk of rhabdomyolysis when used with statins or clarithromycin.
Probenecid 250 BID initially. Titrate up to 2 g per day. NB: High risk of nephrolithiasis; encourage hydration and urine alkalization with potassium citrate; multiple drug interactions
Pegloticase 8 mg IV every two weeks. For refractory gout. Very expensive.
Allopurinol 100mg QD initially, except in pts w/ kidney disease. Effective dose is 300mg QD.
“Genetic testing recommended before initiating treatment in patients at risk of severe hypersensitivity skin reaction (those of Han Chinese or Thai descent, regardless of kidney function, or Koreans with chronic kidney disease stage 3 or greater)” AAFP 2014
Febuxostat 40 mg po QD; may increase to 80mg QD if serum uric acid level > 6 mg per dL. Contraindicated in patients receiving azathioprine (Imuran) and mercaptopurine.