Gout - Treatment

After the first attack, some physicians advise their patients to keep a supply of medications on hand so that self-medication can begin at the first sign of symptoms of a second acute attack.

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Treatments to Prevent Attacks During Intercritical Gout

After an acute attack some patients remain at high risk for another for several weeks during the intercritical period. (Such patients include those with kidney insufficiency or with congestive heart failure who are on diuretics.) In such cases, low doses of either of the following agents may be used to during this period for prevention.

Colchicine
NSAIDs

These agents should be taken in low doses for1 to 2 months after an attack or longer in patients who have experienced frequent attacks. These are simply anti-inflammatory drugs, however, and have no effect on hyperuricemia.

Drugs Used to Reduce Uric Acid Levels in Chronic Gout

In some cases, patients will use agents (antihyperuricemic drugs) to reduce uric acid levels. The goals of antihyperuricemic therapy are to reduce the frequency of attacks and to dissolve monosodium urate (MSU) crystals and tophi. In fact, a 2001 study suggested that patients with chronic gout must maintain uric acid levels at or below 6 mg/dL in order to prevent further attacks.

Candidates. Long-term treatment of hyperuricemia may be recommended for the following situations:

There is a risk for tophaceous gout.
The patient has suffered more than two or three acute attacks of gout.
Attacks are unusually severe or affect more than one joint.
X-rays show joint damage from gout.
Hyperuricemia is caused by an identifiable inborn metabolic deficiency.

Normal kidney function is essential for taking these drugs. This therapy, then, may not be as beneficial in many elderly patients, who often have some kidney insufficiency.

Agents Used to Reduce Uric Acid. A number of effective antihyperuricemic agents are available. In general, their effects differ depending on whether a patient's high uric acid is due to overproduction or a failure to eliminate enough in the urine. They including the following:

Allopurinol. Allopurinol inhibits uric acid production and is useful for those who overproduce uric acid, who have kidney disorders, or who have kidney stones.
Uricosurics. (Most often probenecid and sulfinpyrazone.) They are appropriate when gout is caused by under-excretion of uric acid, which occurs in about 80% of cases. They are not used for patients with reduced kidney function or those with tophaceous gout.

Certain steps must be made in undertaking hyperuricemic therapy:

Some experts recommend a 24-hour collection sample in patients with frequent gout attacks to determine whether they are over-producers or under-excretors of uric acid.
Before starting one of these drugs, any previous acute attack should be completely controlled and the joints should not be inflamed. Some physicians prefer to wait about a month after an attack.
Low doses of NSAIDs or colchicine are used during several months after introducing anti-hyperuricemic therapies to prevent gout attacks that can occur. It should be noted that NSAIDs, particularly aspirin, as well as other salicylate drugs, interfere with uricosuric drugs and reduce effectiveness, so they should be avoided if possible by patients taking these agents.