SLR - May 2021 - Sang Hyub Kim

Therapeutic Approaches in the Treatment of Gout

Reference: Pillinger MH, Mandell BF. Therapeutic Approaches in the Treatment of Gout. Semin Arthritis Rheum. 2020 Jun; 50(3): S24-S30. 

Level of Evidence: Level II

Scientific Literature Review

Reviewed By: Sang Hyub Kim, DPM, MPH
Residency Program: Roxborough Memorial Hospital - Philadelphia, PA 

Podiatric Relevance: Gout is a common condition encountered in the podiatric practices by foot and ankle surgeons. There are many categories of drugs currently available to treat both acute gout flares and established (chronic) gout. This study reviews some of the most recent literature that evaluates the current drug therapy. 

Methods: A level II systemic review of the most current, evidence-based management approaches for acute gout flares, and chronic gout. Descriptions and treatment recommendations are summarized based on a focused search of the most recent literature. 

Results: Four categories are available for management of acute gout flares: Nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, corticosteroids, and anti-IL-1ß biologics. There is no evidence to support the preference of any one NSAID over another. Colchicine is recommended to use with caution in patients with chronic kidney disease. It has adverse reactions with clarithromycin, anti-fungal and anti-retroviral agents. Corticosteroids shows comparable efficacy as NSAIDs, but higher toxicity. Anti-IL-1ß biologics has no likely gastrointestinal, renal or metabolic adverse effects, making it suitable for patients with multiple co-morbidities. For the management of chronic gout, it is indicated that prolonged urate lowering can effectively reduce the frequency of gouty attacks. Xanthine oxidase inhibitors, either allopurinol or febuxostat, are recommended as the initial urate lower therapy agent. 

Conclusions: The authors concluded that the treatment of acute gout flares should be aggressive and should continue until the flare is resolved using one of four anti-inflammatory therapies. Selection of the drugs is based on toxicity, patient co-morbidities, and drug-drug interactions. For management of chronic gout, the authors recommend urate-lowering therapy on some level of treatment for life with modification to lifestyles. Selection of drugs should be based on clinical context, patient co-morbidities and long-term goals. 

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