Factors to Consider in the Long-Term Treatment of Gout

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In the MD Insights program “The ‘Disease of Kings:’ Addressing Misperceptions and Treating Gout Effectively Now and in the Future,” Theodore R. Fields, MD, professor of clinical medicine at Weill-Cornell Medical College, and director of the Rheumatology Faculty Practice Plan at Hospital for Special Surgery, discusses gout diagnosis, misperceptions about the disease, and the consequences of undertreatment of this condition. He also reviews current gout treatment options and discusses potential future treatments.

When initiating gout treatment, allopurinol will be the first option in most cases, especially when looking at long-term management. However, Dr. Fields cautioned that there are quite a few comorbidities frequently associated with gout, with kidney function probably being the most important factor to consider when designing a long-term treatment plan.

Patients with decreased kidney function are at higher risk for allopurinol hypersensitivity syndrome, which tends to happen in the first three or four months of treatment, “and seems to be more likely if you start the dose high rather than building up slowly,” said Fields.

“If someone has decreased kidney function and you choose to give them allopurinol we generally start them on 50 milligram and gradually over several months get them up to the full dose. And that seems to decrease the risk of allopurinol hypersensitivity,” he said.

Febuxostat is also an option in some patients who have decreased kidney function. “We might choose to give them a starting dose that’s approved by the FDA down to a clearance of 30. So we might use that drug in somebody let’s say with a clearance of 40. We might say it’s only 3 percent excreted by the kidney so therefore you can use usual doses of febuxostat in patients with decreased kidney function and they can increase to 80 milligrams without worrying about their kidney function,” Fields said.

To prevent allopurinol hypersensitivity syndrome there are a couple of things that physicians need to keep in mind. Patients with decreased kidney function should be started at a lower dose of allopurinol and then built up slowly. The American College of Rheumatology guidelines from 2012 for management of gout note that patients in certain ethnic groups have a genetic marker that increases their risk of allopurinol hypersensitivity syndrome. A HLA-B*5801 test is recommended before starting these patients on allopurinol. Patients with a positive marker can either be started on febuxostat or initiated on allopurinol but titrated very slowly.

“The medicines that we have now for urate lowering therapy are excellent. Basically we have four options. allopurinol, febuxostat, probenecid, and pegloticase as an intravenous agent.” Said Fields. “The great majority of patients can be managed with these.”