Rheumatology Guideline for the Management of Gout
(Part 4)
We now continue our discussion on the initial use of urate-lowering therapy (ULT) for patients with gout.
Treating gout with the use of allopurinol as the preferred choice of first- line medication is strongly recommended for all gout patients, including those with moderate-to-severe chronic kidney disease (CKD).
Experts strongly advocate the use of allopurinol given its efficacy and lower cost.
Experts add that using a lower starting dose helps prevent the safety issues from happening that is specific to allopurinol hypersensitivity syndrome (AHS).
The choice of either allopurinol or febuxostat over probenecid is strongly favored for patients with moderate-to-severe CKD.
Experts do not recommend pegloticase as a first-line therapy for people with gout.
The starting treatment with low-dose allopurinol which is equal or less than 100 mg/day, and lower in patients with CKD and febuxostat, which is equal or less than 40 mg/day is strongly recommended.
Moreover, the starting treatment using low- dose probenecid, which is 500 mg once to twice daily is conditionally recommended by experts.
A lower starting dose of any ULT reduces the risk of flare linked with drug initiation.
Experts recommend a strong preference for safer ULT prescribing regimens through lower starting doses with subsequent dose escalation, even if such regimens required more blood draws and doctor visits.
The experts explain that lower initial allopurinol doses should be considered in patients with CKD.
While higher starting doses and CKD are linked with risk of AHS, patients with CKD may still require dose adjustment above 300 mg/day to achieve the desired results.
It has been shown in a study that larger body size and diuretic use necessated the need for higher allopurinol doses to get greater urate reduction.
Please remember that it is best to manage gout under the supervision of your rheumatologist.