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).

Gout pain relief is the first stage of gout management. The second stage is treatment to reduce uric acid, but this can cause more pain and many people miss this vital treatment because they cannot tolerate the pain. Recent discoveries regarding gout pain have suggested an alternative approach that may well lead to a new, more effective form of gout pain relief.

Many people mistakenly believe that uric acid crystals, commonly described as needle-like, cause pain in the same way that sticking pins in your body will. If you’ve studied my U-D-R-P model of gout pain, you will know that it is actually your immune system reacting to the crystals that causes swelling and pain in a similar way to fighting a virus. And the pain doesn’t only arise when something triggers these uric acid crystals to form.

A few days after your immune system has attacked uric acid crystals, swelling and pain subside as the crystals become hidden by white blood cells. But you need to reduce uric acid levels to get rid of gout, and whether you do this by diet or by drugs like allopurinol, those gout crystals that were hidden will become visible as they dissolve. This is why most doctors subscribe gout pain relief drugs such as colchicine or other anti-inflammatories (NSAIDS) at the same time as allopurinol. But many people simply cannot stomach these anti-inflammatory drugs and medical researchers are always on the look out for new approaches to gout pain relief.

Recent research into the immune system reaction to uric acid crystals has identified a protein called interleukin-1 (IL-1) as part of the problem. This has long been known to be a factor in rheumatoid arthritis, and a recent study, A Pilot Study of IL-1 Inhibition by Anakinra in Acute Gout, has treated gout patients with the rheumatoid arthritis drug, anakinra. Though this pilot study needs to be confirmed with randomized clinical trials, the authors conclude:

” In this pilot study involving 10 patients with gouty arthritis refractory to conventional therapies, anakinra given at 100 mg daily for 3 days rapidly relieved the inflammatory symptoms of gout. “

It’s good to see that deeper understanding of how gout pain is caused by the immune system has led to scientists looking for different types of treatment. It’s even better to see that applying existing drugs in new ways has led to a real possibility of a new, effective form of gout pain relief.