1. TREATMENT OF THE ACUTE GOUT ATTACK:
“A MATTER OF CONTRAINDICATIONS AND COST!!!” (3)
Colchicine
Cost issue and insurance coverage
Drug interactions
Terkeltaub RA, et al. Arthritis Rheumatol. 2011;63(8):2226.

2. Management of acute gouty attacks
GUIDELINEs
Management of acute gouty attacks
Khanna D, et al. Arthritis Care & Research. 2012;64: Khanna D, et al. Arthritis Care & Research. 2012;64:1447.
Richette P, et al. Ann Rheum Dis Jan;76(1): Qaseem A, et al. Ann Intern Med. 2016; doi: /M
ACR EULAR ACP 2016
Medication First lines:
NSAIDs or
Colchicine (Low-intensity)* or
Steroid
(Oral prednisone 0.5 mg/kg x 5-10 d
stop or 2-5 d at full-dose,tapering in 7-10 d.
or IM triamcinolone mg followed
by oral prednisone
or intra-articular steroid
or IU ACTH subcut for NPO pts.
Switch to different monotherapy
Combination: NSAIDs + Colchicine or
Steroid + Colchcine
Off-label use: IL-1 blockers
Same as ACR 2012
Corticosteroids
(first line)
NSAIDs
(no NSAIDs preference)
Colchicine
(Low-intensity, acknowledge
that is now more expensive
than corticosteroid and
NSAIDs, multiple drug
interactions)
(NOT IMPROVED)
*Low-intensity colchicine: 1.2 mg at first sign, then 0.6 mg an hour later.
- Colchicine is contraindicated in patients on dialysis. (Not dialyzable). Dose should be reduced in patients with renal insufficiency.
- Colchicine dose should be reduced when used in combination with CYP3A4/P-glycoprotein inhibitors.
Strong P-glycoprotein inhibitor: Cyclosporin/Tacrolimus: 0.6 mg 1 dose, to be repeated no earlier than 3 d.
Strong CYP34A inhibitor: Ketoconazole, Clarithromycin, Ritonavir: 0.6 mg 1 dose or 0.3 mg bid, to be repeated no earlier than 3 d
Medium CYP34A inhibitor: Verapamil, Diltiazem: 1.2 mg 1 dose, to be repeated no earlier than 3 d.
Weak CYP34A inhibitor: Azithromycin: No dose reduction required: 1.2 mg at first sign, then 0.6 mg an hour later.

3. LONG-TERM HYPOURICEMIC AGENTs
GUIDELINEs
LONG-TERM HYPOURICEMIC AGENTs
Khanna D, et al. Arthritis Care & Research. 2012;64: Khanna D, et al. Arthritis Care & Research. 2012;64:1447.
Richette P, et al. Ann Rheum Dis Jan;76(1): Qaseem A, et al. Ann Intern Med. 2016; doi: /M
ACR EULAR ACP 2016
Medication First lines (XOI): allopurinol or First lines (XOI): allopurinol or
Febuxostat Febuxostat
- Second line (UUA): probenecid Second lines (UUA): probenecid
(only if CrCl>50 ml/min) or combined (only if CrCl>50 ml/min) or benzpro
XOI with probenecid marone (only if CrCl>30 ml/min,
unavailable in the US) or combined
an XOI with a UUA
No specific recommendation
(Acknowledging available comparable
effectiveness of both allopurinol and
febuxostat)
When
- Frequent attacks > 2 x/yr
- Presence of a tophus
- Nephrolithiasis
- CKD > stage II
- Frequent attacks > 2 x/yr
- First attack, younger than 40
with SUA > 8 mg/dL
- Presence of a tophus
- Nephrolithiasis
Recommends against initiating
long-term urate-lowering therapy after
a first gout attack or in patients with
infrequent attacks.
-Recommends that clinicians discuss
benefits, harms, costs, and individual
preferences with patients before initiating
urate-lowering therapy, including
concomitant prophylaxis in patients with
Recurrent gout attacks.
-”Treat-to-avoid-symptoms”
(meaning???, definition???)
Allopurinol Max. starting dose 100 mg/dL No starting dose recommended
in CKD for any patients with a lower but suggesting low dose.
dose of 50 mg/dL in those with
CKD > stage Max. dose adjusted to CrCl if target not
achieved switch to febuxostat or
- Gradually titrate the dose up by benzbromarone with or without allopurinol
to 100 mg every 2-5 wks to achieve (except in patients with GFR<30 ml/min)
SUA goal as long as adequate patient
education and monitoring drug toxicity
are provided (eg. Pruritus, rash,
elevated transaminase)
“Treat-to-avoid-symptoms, with no
monitoring of urate levels”
(Acknowledging treat-to-target (T2T)
commonly recommended by ACR and
EULAR and requirement of comparative
effectiveness studies that evaluate incre-
mental benefits and harms of a T2T strategy
over treat-to-avoid-symptoms strategy.
Target SUA < 6 mg/dL for all < 6 mg/dL for all
- For severe or tophaceous For severe gout (tophi,
disease < 5 mg/dL frequent attacks) < 5 mg/dL
- SUA < 3 mg/dL not
recommended

4. GUIDELINEs for PROPHYLACTIC TREATMENT
DURING URIC-ACID LOWERING TREATMENT
Khanna D, et al. Arthritis Care & Research. 2012;64: Khanna D, et al. Arthritis Care & Research. 2012;64:1447.
Richette P, et al. Ann Rheum Dis Jan;76(1): Qaseem A, et al. Ann Intern Med. 2016; doi: /M
ACR EULAR ACP 2016
- First line: Colchicine* First line: Colchicine or
NSAIDs
- Second line: NSAIDs
(naproxen 220 mg bid,
unless contraindicated)
Duration: Duration:
- At least 6 months months or
- 3 months after achieving Acknowledge that not all
target SUA if no tophi patients may require
or prophylaxis and discussion
- At least 6 months after with patient recommended
achieving target if tophi present
or the last tophus has resolved
No specific recommendation
(acknowledging evidences available
of using low-dose colchicine or low-dose
NSAIDs for more than 8weeks-6 month)
- Recommends that clinicians discuss
benefits, harms, costs, and individual
preferences with patients before initiating
urate-lowering therapy, including
concomitant prophylaxis in patients with
recurrent gout attacks.
*- Colchicine 0.6 mg once to twice a day. Lower dose is preferred in elderly patients and patients with CKD stage IV-V
(0.3 mg/d or every other day).
- Colchicine is contraindicated in patients on dialysis. (Not dialyzable)
- Colchicine dose should be reduced when used in combination with CYP3A4/P-glycoprotein inhibitors
Strong P-glycoprotein inhibitor: Cyclosporin/Tacrolimus: 0.3 mg/d or 0.3 mg every other day.
Strong CYP34A inhibitor: Ketoconazole, Clarithromycin, Ritonavir: 0.3 mg/d or 0.3 mg every other day.
Medium CYP34A inhibitor: Verapamil, Diltiazem: 0.6 mg/d or 0.3 mg once to twice a day..
Weak CYP34A inhibitor: Azithromycin: No dose reduction required: 0.6 mg once to twice a day.

5. Dalbeth N, et al. Lancet. 2016, 388;