Gout Treatments

Doctors Don’t Always Agree on Gout’s Origins and Treatment


How do rheumatologists and primary care physicians differ in treating patients with gout? This survey highlights some notable differences.

Given that 90% of Gout sufferers are under-excretors rather than over-producers of uric acid, the logical first-line drug should be a uricosuric agent (UUA: Probenecid, Benzbromarone, Lesinurad) rather than a xanthine oxidase inhibitor (XOI: Allopurinol, Febuxostat).

Benzbromarone works very well, easily halving serum uric acid level, and works fairly in moderately impaired renal clearance, but is not in guidelines and unavailable in many countries due to 2 major concerns:
1) hepatotoxicity — this is uncommon, and can be mitigated by close monitoring of liver function tests;
2) nephrotoxicity & kidney stones — this is due to its powerful inhibition of urate re-uptake at the kidneys, and can be mitigated by disciplined hydration.
As such, the guidelines call for a UUA to be only an add-on to an XOI should treatment target fail to be reached, in an attempt to limit the amount of uric acid cascading through the renal system and potentially harming it.

Allopurinol is the cheap and commonplace drug, but has 2 major hurdles:
1) risk of Severe Cutaneous Adverse Reactions (SCAR) including often fatal Stevens-Johnson Syndrome and hepatotoxicity — especially at higher doses, in those with renal impairment, and in carriers of the gene HLA-B5801 (15% of Han Chinese are carriers, it confers a 80-fold risk, but only 2% of carriers develop SCAR on Allopurinol);
2) unwarranted fear of the above limits adequate dosing to achieve treatment target.
The alternative would be the very costly Febuxostat, which is very effective and comes with far lower (but not nil) risk for SCAR.

The true test of the pudding is what your doctor is eating. I’m on Benzbromarone with Colchicine prophylaxis. I hydrate well. My serum uric acid is on target, in fact, < 4mg%. Regular liver and renal function tests are normal. BP has even come down. And I continue to enjoy my food and beverages unrestrained, just eliminating sugary soft drinks. I’ve no further gout attacks beyond my first.

Gout Drugs Compared Side-by-Side

Researchers rank febuxostat as the most effective urate-lowering drug for reaching serum uric acid targets for gout patients.

Comparative efficacy and safety of urate-lowering therapy for the treatment of hyperuricemia: a systematic review and network meta-analysis

The prevalence of hyperuricemia and gout has been increasing, but the comparative effectiveness and safety of different treatments remain uncertain. We aimed to compare the effectiveness and safety of different treatments for hyperuricemia using network meta-analysis methodology.

The aim of this study was to systematically review the literature on effect of initiating urate-lowering treatment (ULT) during an acute attack of gout on duration of index attack and persistence on U

I typically start Urate Lowering Therapy (ULT) at the first encounter with a gout patient, and that’s often in the context of an acute arthritis flare.
Widely held concern that this may worsen or perpetuate the flare is unfounded.