Gout Pal Interactive

Management of recurrent, intercritical and chronic gout

We are all looking for better gouty arthritis cures, but what we need today is better guidelines for using the cures we already have.
British rheumatologists have completed some guidelines for the management of gout, and it is likely that these will influence gout care procedures throughout the world.

I have already reported on the management of the acute phase of gout, which deals mainly with short-term pain relief. This article summarizes the guidance relating to more advanced phases, where the need to cure gout depends on lowering uric acid. The phases that these guidelines refer to are:

Recurrent Gout

Where acute gout attacks occur more than once.

Intercritical Gout

The time between gout attacks. This is, in my opinion, the most overlooked phase. Just because the pain has gone, most people ignore gout during this phase. Big mistake. If uric acid levels are high, you can still get crystals being deposited in the joint and under the skin (tophi). These do not always hurt, but they can build up to the point of serious, painful, chronic gout.

Chronic Gout

This phase is characterized by tophi and severe pain from damaged joints.

The same evidence driven grading applies to these guidelines. The grades are:

1. At least one randomized controlled trial
2. At least one non-experimental descriptive study (eg comparative,
   correlation or case study), quasi-experimental study, or non-randomized controlled study
3. Expert committee reports, opinions and/or experience of respected authorities

Longterm Gout Management Guidelines

The longterm gout management guidelines are:

1. Keep uric acid in the blood below, 300 µmol/l i.e. approx 5mg/dL(C).
   
   
2. You should take uric acid lowering drugs after your first acute gout attack if you have a second attack within one year, and there are no complications(B).
   
   
3. You should also take uric acid lowering drugs if you are a gout patient with:
   • tophi (C)
   • kidney problems (B)
   • uric acid stones (B)
   • the need to continue taking diuretics (B)
     
     
4. If you are not already taking uric acid lowering drugs, wait 1 to 2 weeks after inflammation has gone (C).
   
   
5. If you have uncomplicated gout, you should start uric acid lowering treatment with 50-100 mg allopurinol per day. You should have uric acid blood tests every few weeks, and increase the allopurinol dose by 50-100 mg, until the target (SUA below 300 µmol/l) is reached, but only increase to the maximum dose of 900 mg (B).
   
   
6. If you fall into any of these groups, your doctor may prescribe uricosuric drugs (B):
   1. Kidney function tests show you under-excrete uric acid
   2. Allopurinol doesn’t lower uric acid enough
   3. You cannot tolerate allopurinol

   The preferred drugs are sulphinpyrazone (200-800 mg/day) if you have normal kidney function or benzbromarone (50-200 mg/day) if you have mild/moderate kidney insufficiency (B).
   

7. When you start allopurinol or uricosuric drugs, you should also be prescribed colchicine 0.5 mg twice daily for up to 6 months (A). If you cannot tolerate colchicine, your doctor may prescribe NSAID or Coxib if these are suitable for you, but the duration of NSAID or Coxib should be limited to 6 weeks (C).
   
   
8. If you take aspirin in low doses (75-150 mg/day) to help prevent heart disease, you may continue (B). However, avoid pain-killing doses of aspirin (600-2400 mg/day) as it interferes with uric acid excretion (B).