Treat Chronic Gout with Antihyperuricemic Medications

Overview

Antihyperuricemic medication treats chronic gouty arthritis, tophi, urolithiasis, and recurrent acute gout attacks. It’s often recommended after the first gout attack for patients under 40 or with high urate levels (> 8 mg/dl or 480 µmol/l). It can lower blood pressure, improve cardiovascular prognosis, and slow renal failure progression. Asymptomatic patients with high urate levels, especially those with renal failure, may also benefit. Diuretics can sometimes be replaced by calcium-channel blockers, ACE inhibitors, or ARB (e.g., losartan).

Urate-Lowering Therapy

Medications inhibit urate formation (allopurinol, febuxostat), increase urate secretion (probenecid, benzbromarone), or transform uric acid to allantoin (rasburicase). Allopurinol starts at 100–150 mg/day, increasing to 300 mg/day and up to 600–900 mg/day based on urate targets (< 6 mg/dl or 360 µmol/l). Side effects include abdominal discomfort, rashes, and hypersensitivity reactions. In renal insufficiency, dosage adjusts by GFR. Avoid combining with azathioprine, mercaptopurine, or theophylline.

Febuxostat starts at 80 mg/day, increasing to 120 mg/day. Side effects are similar to allopurinol, and dosage adjusts for severe renal insufficiency (the dose need not be reduced if GFR > 30 ml/min). Do not combine with azathioprine, mercaptopurine, or theophylline.

• Xanthine oxidase inhibitors can start during a treated acute gout attack.
• Anti-inflammatory analgesics, prednisone, or colchicine can manage initial increased attacks.

Probenecid starts at 250 mg twice daily, increasing to 500 mg, but alkalize urine (pH > 6) with sodium bicarbonate (1 g 3-4 times daily for at least one month) initially. It’s contraindicated in urolithiasis or GFR < 50 ml/min. Benzbromarone starts at 50 mg, maintaining at 100–200 mg, suitable for GFR > 20 ml/min but contraindicated in urolithiasis.

Rasburicase is for specific indications in specialized care. Vitamin C (500 mg daily) can reduce uric acid levels. In acute intermittent gout, medication may pause after a year if lifestyle changes maintain urate levels. Chronic gout often needs long-term medication.

Take-home points

1. Start antihyperuricemic medication after the first gout attack if the patient is under 40 or has high urate levels.
2. Consider replacing diuretics with calcium-channel blockers, ACE inhibitors, or ARBs.
3. Adjust allopurinol dosage based on GFR and avoid combining with certain medications.
4. Use febuxostat if allopurinol is unsuitable and monitor for similar side effects.
5. Initiate probenecid with urine alkalization and avoid in patients with urolithiasis or low GFR.
6. Administer rasburicase for specific indications in specialized care.

References

Keywords: Antihyperuricaemic medications, Chronic gout treatment, Gout attack prevention, Allopurinol dosage, Febuxostat use, Probenecid for gout, Renal insufficiency and gout, Uric acid management, Cardiovascular benefits of gout medication, Gout and urate levels