As a pharmacist, you’ll get questions about managing chronic gout due to continued debate over whether to aim for a target uric acid level. We know to consider a chronic medication to lower uric acid when gout causes problems such as tophi or 2 or more acute gout flares/year. But there’s not much evidence on the best way to titrate medications. Some “treat to target” based on limited data that keeping uric acid below 6 mg/dL reduces flares or tophi. Others adjust medications if patients have flares. That’s because patients may have high uric acid, but not experience a flare or have a flare despite a level below 6 mg/dL.
Consider a blended approach to medication titration, that weighs uric acid levels AND history of flares. When a chronic gout medication is needed, stick with allopurinol (Zyloric). Typically begin treatment 1 or 2 weeks AFTER flare resolution.
- Start with allopurinol (Zyloric) 100 mg/day or 50 mg/day if CrCl is below 60 mL/min to reduce hypersensitivity risk.
- Check labs and increase the dose every 2 to 4 weeks. Generally, aim to get uric acid below 6 mg/dL.
- Once patients are stable on allopurinol, monitor serum uric acid about annually.
- But don’t feel compelled to adjust the dose if patients don’t report flares even if their uric acid level is up.
- Check adherence to allopurinol before making dose changes.
- If needed, increase up to 800 mg/day in normal renal function, or 300 mg/day or even higher in kidney disease.
- Advise patients to stop allopurinol and call for a new rash or itching especially within 2 months of a dose increase.
- Save other medications for when patients can’t take allopurinol.
- Lean away from febuxostat (Xanthistop) due to its cardiovascular risk or probenecid due to many interactions and risk of kidney stones.
- Products with lesinurad (Zurampic) are off the market due to low demand.
- Give an NSAID, low-dose colchicine, or oral steroid when starting a uric acid-lowering medication since this can trigger a flare.
- Educate patients to continue chronic gout medications during a flare. For further information, see note on "Comparison of gout therapies".
References
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FitzGerald JD, Dalbeth N, and others. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol. 2020 Jun;72(6):879-895. Available at: https://pubmed.ncbi.nlm.nih.gov/32390306
Research, C. for D.E. and (2019). FDA adds Boxed Warning for increased risk of death with gout medicine Uloric (febuxostat). FDA [online]. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-boxed-warning-increased-risk-death-gout-medicine-uloric-febuxostat
Qaseem A, Harris RP, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Jan 3;166(1):58-68. Available at: https://pubmed.ncbi.nlm.nih.gov/27802508
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