Agents used for gout
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.
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.
12 biweekly IV infusions for 6 months in patients
Uricosuric drugs (for long-term uric acid lowering)
Author avoids (only effective in under-excreters of uric acid).
Other agents that may affect gout
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.
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4. Choi HK, Soriano LC, Zhang Y, Rodrguez LA. Antihypertensive drugs and risk of incident gout among patients with hypertension: population-based case-control study. BMJ. 2012;344:d8190. doi:10.1136/bmj.d8190.
5. Ruilope LM, Kirwan BA, de Brouwer S, et al; ACTION Investigators. Uric acid and other renal function parameters in patients with stable angina pectoris participating in the ACTION trial: impact of nifedipine GITS (gastro-intestinal therapeutic system) and relation to outcome. J Hypertens. 2007;25:1711-1718.