CLINICAL

The management of gout:

Much has changed
Philip C Robinson, Lisa K Stamp

Background
Gout is a common problem that is
increasing in prevalence in Australia.
It is associated with many serious
comorbidities such as hypertension,
chronic kidney disease, obesity, diabetes
and cardiovascular disease. Recent
changes include the way that older drugs
are used, as well as newer therapeutics
becoming available or in development.

Objective
The objective of this article is to provide
an update on the management of gout.

Discussion
Developments in treatment strategies
for gout and newer agents to treat gout
are discussed in this article. The salient
points include the need to treat gout
to a serum urate target, the ability to
start allopurinol during acute attacks,
the need to treat with prophylactic
anti-inflammatory drugs for adequate
time periods, and the availability of
a new urate-lowering drug on the
Pharmaceutical Benefits Scheme (PBS).

out is not a new disease, but its

management has certainly seen
much change in the past five years.
It is increasingly being recognised as a
serious disease that causes functional
disability, increased work absence, and
negative economic consequences for
the individual and community.1 Australian
research indicates that gout is a significant
and increasing problem, with at least
1.5% of the general population affected.
A very high prevalence (>10%) of the
disease is seen in specific groups, such
as elderly men.2,3 Evidence from Australia
and the rest of the world shows that
the management of gout is suboptimal,
as demonstrated by infrequent serum
urate testing, low levels of urate-lowering
therapy prescription and, when prescribed,
inadequate dosing, resulting in serum urate
levels above target.
There have been a number of changes
to the management of gout, including
dosing strategies of older drugs and
availability of newer therapeutics. This
review provides an update for practitioners
on the management of gout.

Common misconceptions
Gout does not occur only in the great toe
(podagra), although this is a common site
for the initial episode. It can affect any
joint in the body and can even mimic the
polyarthritis of rheumatoid arthritis.
If inadequately treated, it is a condition
that usually progresses rather than
regresses. Accumulation of urate in the
body occurs as a result of an imbalance

The Royal Australian College of General Practitioners 2016

in intake or intrinsic urate production

and excretion through the kidneys and
gastrointestinal tract (GIT). Kidney and GIT
excretion is influenced mainly by genetics,
although factors such as concomitant
medications also play a role.

Gout growing in prevalence

and impact
Gout has often been viewed as a
nuisance and non-serious condition. It is
an important condition for a number of
reasons.
First, gout is increasing in prevalence
as the world population becomes more
overweight and obese.4
Second, gout causes significant pain,
functional impairment and reduction in
work participation. Studies have found that
those with gout are absent more often
from work and take more sick leave than
those who do not have gout.5 This has an
impact not just on the patient but also on
their finances, family and community as a
whole.
Third, gout is associated with a
number of serious comorbidities such as
hypertension, diabetes mellitus, ischaemic
heart disease, kidney disease and obesity.
Therefore, patients who present with
gout have a very high chance of another
serious and treatable condition that can be
screened for and treated. It is important
to identify comorbid conditions as they
have an impact on the therapeutic options
for gout.6 The therapies used to treat
comorbidities also need to be considered
carefully. There are treatments that:1,7

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raise serum urate (eg thiazide, loop

diuretics)
impair the actions of urate-lowering
drugs (eg frusemide)
lower serum urate (eg losartan).
Consideration of potential comorbid
conditions, their treatment and their
possible impact on gout is therefore
critical.

Treat to target
Treating patients to a target serum urate
is essential for reducing gout flares and
resolving tophi. For those without tophi, a
target of <0.36 mmol/L is recommended;
for those with tophi, a target of <0.30
mmol/L should be considered.8 Gout flares
decrease with decreasing levels of serum
urate. Once the serum urate is below
target, gout flares may still occur for up
to 1218 months. They should become
more infrequent over time if the serum
urate target is maintained, and will stop
eventually.

Acute flare treatment

Treatment of acute flares should begin
as soon as possible. Non-steroidal
anti-inflammatory drugs (NSAIDs) or
colchicine are considered first-line agents;
oral corticosteroids are reserved for
those who cannot tolerate, or who have
contraindications, to first-line agents.9
NSAIDS are typically used at full dose.
Colchicine 1.2 mg immediately followed
by 0.6 mg six hours later and then 0.6mg
once or twice daily for two to three days
for those with normal renal function is
often effective (note, the 0.6 mg tablet
size is not available in Australia and the
0.5 mg tablet is usually substituted for
it).9 It is not usually associated with
the gastrointestinal adverse effects
commonly seen with higher doses. Even
lower colchicine doses are required for
those with renal impairment or receiving
CYP3A4 or P-glycoprotein inhibitors.10
Oral corticosteroids, such as 0.5 mg/kg
prednisone for five to 10 days with gradual
reduction or an intra-articular steroid
injection for those with a monoarthritis
due to gout, can be very effective.9

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Allopurinol should not be stopped

during acute flares of gout
Allopurinol should not be stopped during
acute flares of gout.11 Stopping allopurinol
during an acute flare means therapeutic
effect is lost and the urate level will rise.
In addition, there is a real risk of the
allopurinol not being recommenced as
well as precipitating another flare when it
is recommenced.

Allopurinol can be started during

an acute attack
Historically, there has been concern that
starting urate-lowering therapy such as
allopurinol could worsen or prolong the
acute gout flare. Two small clinical trials
have now found that this is not an issue.
Based on these trials, it is reasonable
to start allopurinol during an acute flare
of gout when combined with acute
gout treatment as this does not prolong
the flare.12,13 In addition, it is an ideal
opportunity to initiate therapy and educate
the patient while they have the acute
symptoms, which are a more immediate
reminder of the reason for the new
therapy.

Allopurinol needs to be started

low and up-titrated
Evidence suggests that it is the starting
dose of allopurinol, not the maintenance
dose, that increases the risk of allopurinol
hypersensitivity syndrome (AHS).14
Therefore, allopurinol should be started at
50100 mg per day (or less in those with
severe renal impairment) and titrated up
so patients reach their serum urate target.
The American College of Rheumatology
recommends that everyone commencing
allopurinol start on 100 mg per day, except
those with stage 4 or worse chronic
kidney disease, where the recommended
starting dose is 50 mg per day.8 It should
then be titrated up every two to five
weeks, with more caution and longer
intervals in those with poorer kidney
function.
For example, in a patient with gout, no
tophi and normal kidney function, one
might start at 100 mg a day for two to

three weeks, then increase to 200 mg per

day for two to three weeks, then 300mg
per days for two to three weeks.8 The
serum urate should then be checked and,
if the target (<0.36 mmol/L) has been
reached, the patient can stay on 300 mg
per day. If not, the dose is then titrated up
to 400 mg per day and the serum urate is
checked again. In Australia, the maximum
recommended dose of allopurinol is
900mg.15
The risk of AHS is increased in those
who carry the HLA-B*5801 allele, which
has an increased prevalence in those of
Asian descent. Guidelines recommend
testing for this allele in high AHS-risk
individuals such as people of Asian
descent with renal impairment, then
avoiding allopurinol if it is present.8

Prophylaxis of acute gout flares

Prophylaxis of acute flare of gout is
recommended in those commencing on
urate-lowering therapy. Gout flares on
starting urate-lowering therapy are very
common and prophylaxis aims to prevent
them from occurring. In a trial of allopurinol
where prophylaxis was ceased, a flare
rate of 64% was observed.16 In those
receiving naproxen (250 mg twice daily)
or colchicine (0.6 mg daily) prophylaxis,
2028% of patients experienced flares
on initiation of urate-lowering therapy.17
Although no head-to-head trials have been
completed, the available data suggest that
flare rates are substantially reduced by
anti-inflammatory prophylaxis. NSAIDs or
colchicine are the first-line recommended
agents.8 This can be achieved by a
moderate dose of an NSAID, such as
naproxen 250 mg twice daily, or 0.51 mg
of colchicine per day.9 Consideration of
medication contraindications and use of
gastric protection may be appropriate.
The recommended duration of
prophylaxis is now longer than what has
previously been used. The American
College of Rheumatology recommends:
at least six months duration, or
three months duration after achieving
target serum urate in patients without
tophi, or

The Royal Australian College of General Practitioners 2016

THE MANAGEMENT OF GOUT CLINICAL

six months duration after achieving

target serum urate in patients with
tophi on examination.
This recommendation is in recognition that
even after the target serum urate level
has been reached, flares may continue
to occur for some time.8 Every clinical
scenario is different and practitioners need
to carefully consider the risks and benefits
when prescribing prolonged courses of
acute gout flare prophylaxis.

Monitoring of serum urate

Once target serum urate has been
reached, six-monthly monitoring by
testing serum urate is recommended to
ensure continuing adequate management
and adherence.8 This includes monitoring
serum urate, and checking use of
blister packs. Adherence with longterm allopurinol is poor and every effort
should be made to encourage patients
to continue to take it, including involving
family members.

Febuxostat as an alternative
urate-lowering therapy
Febuxostat is a newer agent used
to treat gout that works by inhibiting
xanthine oxidase the same mechanism
as allopurinol. It is now available on the
Pharmaceutical Benefits Scheme (PBS)
as an authority required drug for patients
with gout who have a contraindication
to allopurinol or a documented history
of AHS, or intolerance to allopurinol
necessitating permanent treatment
discontinuation.18 This would therefore
be appropriate in patients with allopurinol
rash or AHS. In addition, it would be
appropriate therapy for those who have
HLA-B*5801.

Management of gout in
those with severe chronic
renal impairment
The evidence guiding the management
of those with gout requiring uratelowering therapy and an estimated
glomerular filtration rate (eGFR) <30mL/
min is limited. One approach is to
start the patient on a very low dose of
allopurinol (eg 1.5 mg per mL eGFR) with
very gradual up-titrating (eg 2550 mg
per month). An alternative is the use of
lowdose febuxostat, although evidence
to support this approach is currently
sparse.19 Referral to a rheumatologist is
recommended.

Conclusion
The increasing prevalence and impact of
gout mean that greater focus is required
to ensure best outcomes for patients.
Newer therapeutic agents are on the
horizon, but gout can still be well treated
with our current agents, especially in
light of recent insights into treatment
strategies, such as commencing
allopurinol during acute attacks and
starting at a low dose and titrating up.
Generally speaking, the most important
strategy is to treat to a serum urate target
(<0.36 mmol/L in most people) as this
is critical to preventing gout flares and
resolving tophi.

Start urate-lowering therapy with prophylaxis

Ensure patient has acute flare plan (see text for further details)

Once target achieved, monitor 612 monthly

The Royal Australian College of General Practitioners 2016

No current guidelines or
recommendations in the US, UK, Australia
or New Zealand support treatment of
asymptomatic hyperuricaemia.

Research has suggested that patients

with gout who lack confidence in their
treatments have reduced adherence to
their medications. A lack of confidence
in treatment can result from their gout
flaring after initiation of urate-lowering
therapy.20 Education about this and other
aspects of gout is important to make
sure patients understand that although
their gout may flare in the short term,
they are moving towards a shared goal
of no gout attacks in the long term.21,22
In addition, equipping patients who have
gout with the skills and motivation to be
adherent with medication is likely to also
be very important.
A large intake of sugar or sweetened
soft drinks, such as cola or lemonade, is
a recognised risk for gout. Patients with
gout are advised to limit their intake of
these beverages.8
Although epidemiological evidence
suggests that a high-purine diet
increases the risk of gout, there is scant

Set urate target

Titrate urate-lowering therapy to achieve target

Treatment of asymptomatic
hyperuricaemia

Patient education

Box 1. Gout treatment schema 23

Monitor serum urate until target reached

evidence that introducing a low-purine

diet in those with gout results in a
clinically meaningful reduction in gout
flares or serum urate.
A comprehensive approach is best,
including providing patients with a
schema to help them understand
important aspects of gout management
(Box 1).

Authors
Philip C Robinson MBChB, PhD, FRACP, Senior
Lecturer, University of Queensland School
of Medicine, QLD, and Staff Specialist in
Rheumatology, Royal Brisbane and Womens
Hospital, Herston, QLD. philip.robinson@uq.edu.au
Lisa K Stamp MBChB, PhD, FRACP, Professor of
Medicine, Department of Medicine, University
of Otago, Christchurch, New Zealand, and
Rheumatologist, Rheumatology Department,
Christchurch Hospital, Christchurch, New Zealand
Competing interests: Philip C Robinson has
received research funding and consulting fees
from AstraZeneca, and consulting fees from
Menarini and Novartis. Lisa K Stamp has received
consulting fees from AstraZeneca.
Provenance and peer review: Not commissioned,
externally peer reviewed.

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