PAIN MANAGEMENT: New treatment for gout
Tom, a 50-year old construction worker, has a 20-year history of gout. On average, he suffers five to six gout attacks every year, affecting his toes, ankles, feet or knees. His uric acid level is 12.1 mg/dl.
Factors which contribute to high uric acid in our blood are either genetic (over-production or under-excretion of urate) or lifestyle-related (overweight and over consumption of fructose or alcohol), or a combination of both.
High uric acid is a true risk factor for gout. The best way to help reduce the risk of gout attacks is to reduce uric acid in the blood to less than 6 mg/ml.
Urate-lowering therapy is the most effective way to prevent gout attacks. Allopurinol (Zyloporim), a purine analog and an inhibitor of the enzyme xanthine oxidase, can inhibit purine synthesis and uric acid production. Therefore, allopurinol can prevent gout attacks, decreasing the potential kidney damage from gout, and even resolving the existing crystal deposits.
However, allopurinol will not relieve a gout attack that has already started. During a gout attack, the initiation of allopurinol treatment or changing the dose of allopurinol should be avoided.
Colchicine or NSAIDs need be taken for six months during allopurinol treatment to prevent gout flare-ups. After the uric acid has remained at normal levels for a while, the dose of allopurinol can be gradually decreased until the smallest amount of allopurinol that can keep the uric acid less than 6 mg/ml is reached.
Common side effects of allopurinol include upset stomach, diarrhea and dizziness. Some uncommon, but serious side effects of allopurinol, are skin rash, swelling of the lips or mouth, or itching. Allopurinol doses need to be adjusted for patients with moderate renal impairment.
Febuxostat (Uloric) works by blocking an enzyme called a non-purine xanthine oxidase, which helps prevent uric acid production and lowers elevated uric acid levels. This medication is generally recommended for those who cannot take allopurinol.
Unlike allopurinol, very little Uloric is excreted through the urine, making Uloric safe for patients with kidney problems. No dose adjustment appears to be necessary in those with moderate renal insufficiency and hepatic impairment.
The most commonly reported adverse events were liver function abnormalities, nausea, joint pain and rash. In general, side effects are mild and tolerable.
Uloric works more quickly and effectively than allopurinol. Although Uloric can lower serum urates within a few weeks, urate crystals take much longer to dissolve. Zurampic (lesinuard) is a urate transporter inhibitor and is recommended together with allopurinol or febuxostat when these medications are not sufficient.
High serum uric acid is not only a risk factor for gout, but adversely affects kidney function and can increase cardiovascular events. Thanks to the new medications, high uric acid is much more easily controlled than ever before.
— Dr. Yong H. Tsai is board-certified in rheumatology, allergy and clinical immunology and has been practicing in this area since 1993. His website is arthritis-allergy.net.