"Gout prophylaxis: Why, how, and for who?"- Dr. Rohini Handa
M3 India Newsdesk Jun 06, 2019
Dr. Rohini Handa explains that while gout is well understood, it is often a poorly managed condition, and much like handling flares among patients, it is also important to include another aspect of management that is often overlooked- prophylactic therapy.
Gout is common in clinical practice. The troika of drug treatment of gout comprises management of acute attack, treatment of hyperuricaemia- the underlying biochemical abnormality, and prophylaxis in patients with recurrent flares. This write up addresses the issue of prophylaxis in patients with gout.
What is a flare ?
A gout flare (also known as ‘attack’) is a clinically evident episode of acute inflammation induced by monosodium urate crystals (Bursill et al. Arthritis Care Res (Hoboken) 2019:427-434). The frequency and site of gout flares is variable. Lower limb joints are preferentially affected especially the big toe (podagra), although no joint is exempt.
Why should clinicians bother about gout flares ?
Flares are a defining feature of gout and reported by as many as one-fourth to one-third of the patients with gout (Proudman et al. Arthritis Res Ther 2019; 21:132). Despite being common, the issue of flare prophylaxis is uncommonly addressed by clinicians. Patients and doctors often stop treatment after the acute attack subsides. Flares adversely impact quality of life in gout. Tackling attacks only, while overlooking prophylaxis, amounts to winning just one battle while losing the war!
Who merits prophylaxis ?
Predicting who will flare is difficult. After resolution of an acute attack some patients remain symptom free for years while some patients experience recurrent episodes. Patients with higher serum urate levels (>8 mg/dL]) are at greater risk. Shifts in serum urate induced by institution of allopurinol, febuxostat or uricosurics may precipitate acute attacks.
Prophylactic therapy reduces the frequency of attacks by 75-85% and mitigates the severity of attacks that do occur.
Flare prophylaxis is recommended in the following situations:
- During the first 6 months of urate lowering treatment (ULT).
- Patients with recurrent attacks of gout (>2-3 per year)
- Problematic gout like tophaceous gout or chronic kidney disease (CKD)
Recurrent gout may need prophylaxis for 6-12 months in addition to ULT while tophaceous gout may need indefinite prophylaxis till the tophi resolve.
The agents used for gout prophylaxis include colchicine and non steroidal anti-inflammatory drugs (NSAIDs). Most of the available evidence supports the use of colchicine over NSAIDs.
- The use of corticosteroids for flare prophylaxis is not recommended. This is not to be confused with acute gout where corticosteroids are effective and recommended.
- The high cost of IL-1 inhibitors precludes their routine use for prophylaxis.
- Low doses of colchicine (0.5 mg twice daily) are recommended for prophylaxis. Some patients may need just once daily dose. Colchicine needs dose adjustment for renal impairment, potential drug interactions, or intolerance.
As per British Society of Rheumatology guidelines there is no need for reduction in colchicine dosage for flare prophylaxis in patients with mild renal insufficiency (eGFR >60 ml/min) while the dose should be limited to 0.5 mg od in those with an eGFR of 30-60 ml/min and to 0.5 mg every 2-3 days with eGFR 10-30 ml/min while it should be avoided altogether if eGFR<10 ml/min. Physicians should also be aware of potential neurotoxicity and/or muscular toxicity in patients on concomitant statins. Co-prescription of colchicine with CYP3A4 inhibitors such as cyclosporin, clarithromycin, verapamil, and ketoconazole should be avoided.
No drug treatment can be successful without patient education.
- It is incumbent on all physicians to educate gout patients about lifestyle: weight loss if warranted, regular exercise, avoidance of alcohol (especially beer and whiskey) and sugar-sweetened carbonated drinks, binge eating and excess intake of red meat and certain seafood.
- Low fat dairy products should be encouraged. Education improves adherence.
- It is also mandatory to screen all patients for associated comorbidities like obesity, dyslipidaemia, renal impairment, coronary heart disease, peripheral arterial disease, hypertension, diabetes and smoking.
Gout is a well understood but poorly managed condition. Prophylaxis is an unmet need in gout management.
Prophylaxis in Gout: Fact File for a Clinician
- Flares are common in gout
- Always institute flare prophylaxis while starting urate lowering treatment (ULT)
- Other situations that warrant prophylaxis include: recurrent attacks of gout (>2-3 per year), tophaceous gout or CKD
- Colchicine 0.5 mg twice daily for 6 months is the preferred agent when starting ULT
- Recurrent gout may need prophylaxis for 6-12 months while tophaceous gout may need indefinite prophylaxis till the tophi resolve
- If colchicine is not tolerated or is contraindicated, prophylaxis with low dose NSAIDs, if not contraindicated, can be considered
- Corticosteroids are not recommended for flare prophylaxis in gout
- The use of prophylactic colchicine does not replace the need for ULT; colchicine use without control of hyperuricemia may be detrimental as tophi may develop without the usual warning attacks of acute gout
The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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