Notes for: Gout & Cytotoxic Induced HyperiuicaemiaLast edited [21/08/2013 14:36:09]
1. Acute attacks of gout should be treated with high doses of NSAIDs such as naproxen, diclofenac or etorixcoxib. Aspirin is not indicated in gout. If considering etoricoxib in acute gout note that it is contraindicated in patients with inadequately controlled hypertension, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease.
2. Allopurinol is indicated for gout prophylaxis but its use may precipitate an acute attack of gout and so it must not be initiated during an acute attack. Therefore, colchicine or NSAIDs should be used as an initial prophylactic and continued for at least one month after the hyperuricaemia has been corrected.
3. When used for prophylaxis, allopurinol should be introduced slowly as this will lessen the risk of the occurrence of acute attacks. The dose of allopurinol may be increased above 300 mg daily if patients tolerate it. Higher doses should be tried before swithcing to febuxostat because of lack of efficacy.
5. Febuxostat may be used if the patient is intolerant of or has contraindication to llopurinol - NICE Guidance on Febuxostat for the management of hyperuricaemia in people with gout (TAG 164, December 2008). Starting dose is 80mg daily. Check urate after 4 weeks and if serum urate >0.36mmol/L increase dose of febuxostat to 120mg od then check urate after 4 weeks and if serum urate >0.36mmol/L contact rheumatology department for advice.
6. The dose of allopurinol should be reduced in patients with renal failure.
7. Colchicine is an alternative in patients for whom NSAIDs are contrainducated. The use of colchicine may be limited by the development of toxicity at higher doses, but it is of use in patients with heart failure since it does not induce fluid retention and can be given to patients receiving anticoagulants, unlike NSAIDs. When used in acute gout colchicine dose is 1mg initially followed by 500 micrograms every 2 to 3 hours until relief from pain is obtained or vomiting or diarrhoea occurs or until a total dose of 6mg (12 tablets) is realised. When used as prophylaxis whilst introducing a urate lowering drug dose is 500 micrograms twice daily.
8. Patients on anti-gout therapy should be advised to increase their fluid intake.
9. Prevention of recurrent gouty arthritis:
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One attack, or several attacks separated over many years, are not indications to institute preventative therapy with allopurinol.
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Look for a cause of hyperuricaemia.
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Do not start therapy until acute attack is over or it may become prolonged.
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Cover initial period on allopurinol or febuxostat with NSAID or colchicine, often for several months.
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A low purine diet and alcohol restriction may help (specifically the avoidance of dietary fats, alcohol, sardines, anchovies, liver and sweetbreads).
Guidelines on management of gout available from: The British Society for Rheumatology and British Health Professionals in Rheumatology.