|Treatment recommendations for gout|
|Agents used for gout||Dosing/comments|
|Allopurinol (long-term uric acid lowering)||Start slowly (50 - 100 mg/d); titrate up to 800 mg/d. Increase dose every 2 - 4 weeks. To reach target uric acid level of 6 mg/dL, start 2 - 4 weeks after acute attack has resolved. Decrease dose in patients with CKD. Exercise caution in patients with CKD4 or worse.|
|Febuxostat (long-term uric acid lowering)||Daily doses of 80 and 120 mg were, respectively, 2.5 and 3 times more likely to achieve urate levels of < 6 mg/dL as was 300 mg of allopurinol. With creatinine clearances of 30 – 89 ml/min, 80- and 40-mg doses of febuxostat were superior to 200 - 300 mg of allopurinol in lowering uric acid to 6 mg/dL. This is a second-line agent for people who have prohibitive adverse effects with or who fail to respond to allopurinol. Safety data are lacking in patients with advanced CKD.|
|Colchicine (acute attacks)||Use low-dose regimen: 1.2 mg PO followed once by 0.6 mg PO 1 hour later, then stop.a|
|Corticosteroids (acute attacks)||Prednisone, 40 mg/d for 5 days, especially in patients with CKD4 or worse. May be administered intra-articularly if only 1 or 2 joints are involved.|
|NSAIDs (acute attacks)||Avoid in patients with renal, hepatic, cardiac failure or with history of GI bleeding; use with caution in the elderly; use with proton pump inhibitor. There are no data for celecoxib efficacy.|
|Pegloticase||12 biweekly IV infusions for 6 months in patients refractory to conventional treatment for lowering uric acid levels.|
|Uricosuric drugs (for long-term uric acid lowering)||Author avoids (only effective in under-excreters of uric acid).|
|Other agents that may affect goutb Favored antihypertensives: losartan, amlodipine, nifedipine||Do not increase the likelihood of gouty attacks; both losartan and nifedipine may lower uric acid levels.|
|Low-dose aspirin, cyclosporine, thiazides||Increase likelihood of gouty attacks. Relative risk for gouty attacks with antihypertensives: 0.87, calcium channel blockers; 0.81, losartan; 2.36, diuretics; 1.48, -blockers; 1.24 ACE inhibitors; 1.29, non-losartan ARBs.|
|CKD, chronic kidney disease; CKD4, stage 4 chronic kidney disease; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blockers.
a Author does not use for long-term prevention of attacks.
b These agents are not used to treat gout, but their use may have an effect on gout.
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