Strategies to reduce the likelihood and impact of gout flare following initiation of urate lowering therapy

Strategies to reduce the likelihood and impact of gout flare following initiation of urate-lowering therapy (ULT)

• advise the patient that an attack of gout may occur following initiation of ULT and reassure them that this is a sign that ULT is working
• ULT should not be stopped if an acute attack of gout occurs. If started during an attack of gout, ULT can exacerbate that attack and hence it is customary to wait for 1-2 weeks after an acute attack has resolved before commencing ULT
• ULT should be started in low dose (e.g. allopurinol 100 mg daily) and escalated gradually, titrated to serum urate levels and renal function
  • allopurinol is the recommended first-line ULT (urate lowering therapy) to consider. It should be started at a low dose (50-100 mg daily) and the dose then increased in 100 mg increments approximately every 4 weeks until the sUA (serum uric acid) target has been achieved (maximum dose 900 mg) (2)
    • in patients with renal impairment, smaller increments (50 mg) should be used and the maximum dose will be lower, but target urate levels should be the same
• colchicine 0.5mg bd or od should be considered as prophylaxis against acute attacks resulting from initiation or up-titration of any ULT and continued for up to 6 months (2)
  • in patients who cannot tolerate colchicine, a low-dose NSAID or coxib, with gastroprotection, can be used as an alternative providing there are no contraindications

Reference:

1. Arthritis Research UK (2011). Hands On (9) - gout: presentation and management in primary care.
2. Hui M et al. for the British Society for Rheumatology Standards, Audit and Guidelines Working Group, The British Society for Rheumatology Guideline for the Management of Gout, Rheumatology (2017), 56 (7): 1056-1059, https://doi.org/10.1093/rheumatology/kex150