Gout

Long-term treatment to lower uric acid and prevent gout attacks and long-term problems

There are three reasons for treating gout:

•    reducing the pain and inflammation caused by an acute attack 
•    preventing future attacks
•    preventing joint damage or kidney problems
People who only have occasional attacks of gout, for example an attack every few years, might only need treatment to deal with these attacks (For more see ‘Treating the pain and inflammation of attacks’). However, it is recommended that GPs and/or rheumatologists discuss long-term treatment with everyone who has gout*. People who have more frequent attacks may need daily medication for the rest of their lives to reduce the amount of uric acid (urate) in their blood and prevent further attacks or joint damage. 
How does ongoing treatment prevent attacks and long-term damage?

Long-term joint damage and formation of tophi (small white lumps under the skin) can be caused by a continued build-up of uric acid crystals. Crystals can damage the cartilage and bones, leading to long-term arthritis. If people do not take long-term treatment for gout, uric acid can sometimes form kidney stones. The drugs used to relieve symptoms of a gout attack do not get rid of uric acid crystals in the joints or reduce the level of uric acid in the blood, but ongoing treatments, like allopurinol, can do this. 
Reducing the levels of uric acid prevents new crystals from forming. It also slowly dissolves the crystals that are already there. It can take up to 2 years of daily medications to completely clear the body of crystals, and then further attacks of gout and joint damage are unlikely. Even when the crystals have been dissolved, long-term treatment is still needed once a day to keep levels of uric acid within the normal range and prevent new crystals from forming.

Starting long-term treatment 

Ongoing treatment is usually recommended for people who are having frequent attacksor have complications of gout: people who have tophi, kidney stones or signs of joint damage, and people who have very high levels of uric acid in their blood. Currently there is no expert agreement on how frequent attacks need be before long-term treatment is recommended. Sometimes it might be suggested after one attack, and in other cases GPs or specialists may prefer to wait until two or more attacks have occurred over a 12 month period. However, it is recommended that GPs and/or rheumatologists discuss long-term treatment with everyone who has gout*.

People sometimes find that starting long-term treatment triggers an attack. This is because the crystals start to dissolve and become smaller, and can then move around more easily. Daily non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine can be taken to supress inflammation while the ongoing treatment begins to reduce the levels of uric acid. It can take up to 2 years for crystals to be completely cleared from the body, so people may continue to have attacks during this time.
Two long-term medications for gout are allopurinol and febuxostat.

Allopurinol

This is the most commonly used drug. It is usually taken once a day, and works by lowering the amount of uric acid produced by the body. After uric acid levels are measured, people are usually prescribed a low dose to start with. This is because, if levels of uric acid are reduced too quickly, an attack can be triggered. Starting at a low dose also reduces the risk of unwanted side effects (for more see ‘Side effects of gout medication’).
Uric acid levels will then be tested after about a month, and the dose will be increased by 100mg if the levels have not come down to within the normal range. This process of checking uric acid levels and increasing the dose may need to happen several times to get to the dose that is enough to keep the uric acid levels low enough (below 360µmol/L). Many people need 400-500mg a day. The maximum dose is 900mg a day. Allopurinol is available as 100mg and 300mg tablets, so even if you are on a higher dose you should not have to take many tablets. 
Once uric acid levels are within the normal range and attacks have stopped, the tablets should be continued every day. Blood tests should be done every one or two years to make sure that the uric acid levels are still low enough (less than 360µmol/L).
Long-term treatment is not usually started during an attack because the drug could make the attack worse. It also means that the pain people have during an attack does not affect their decisions about treatment options. Ongoing treatment is usually started between 2-4 weeks after an attack has ended, although a research found that people who started allopurinol during an attack had no more pain than those who did not [Taylor, Mecchella, Larson, Kerin and MacKenzie, 2012]. 
If people have side effects from allopurinol such as a rash, nausea, headaches or indigestion, they should stop taking the tablets and ask their doctor for advice. Lower doses, and more caution when increasing doses, are needed for people who have kidney problems because they are at more risk of side effects. Allopurinol can also affect some other tablets, like warfarin and azathioprine, so people must tell their doctor if they are taking these drugs.

Febuxostat

Febuxostat is the main alternative to allopurinol. Febuxostat is suitable for some people who cannot take allopurinol, and it does not affect warfarin. It is not recommended for some people with heart problems, people who have had organ transplants or people who are taking azathioprine (used to treat a variety of long-term conditions, such as inflammatory bowel disease).
Other options

Low doses of colchicine can be taken every day to reduce the tendency for attacks. However, this will not get rid of crystals or prevent long-term joint damage because colchicine does not reduce the levels of uric acid in the blood. 

Other drugs can be used to reduce uric acid levels for people who cannot take allopurinol or febuxostat. These drugs increase the amount of uric acid that is removed from the body in urine. They include sulfinpyrazone, probenecid and benzbromarone. It is best for people who cannot take allopurinol or febuxostat to discuss these options with a specialist. 

(For more see ‘Decisions and feelings about treatments’.)

*EULAR guideline – Richette et al Ann Rheum Dis 2016


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Last reviewed December 2016
Last updated December 2016

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