Agents in the Management of Patients With Gout
In this video, Monica Richey, MSN, ANP-BC/GNP, discusses the agents that are available in the management of patients with gout, the possible challenges and complications clinicians should consider in available agents, and the treatment of patients with chronic gout vs acute gout.
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Monica Richey, MSN, ANP-BC/GNP: My name is Monica Richey. I'm a nurse practitioner, and I've been practicing in rheumatology since 2005. So, I'm about to make 20 years in the area. I love rheumatology. It's a very fun specialty. You always have a surprise in your day.
Consultant360: What agents are available in the treatment of patients with gout?
MR: Alright. So, there are quite a few, but usually, we stick to the usual suspects. Right? Colchicine is used, very old drug, 0.6 milligrams. And we only use that during flares, really to manage the flare of gout. That is not used to control gout.
Then, we have the old one that is allopurinol, which is also very safe. We use any dose from 100 to 800 milligrams to try to bring the uric acid down. So, that is really the medication that will bring the uric acid down. Different than colchicine which does not touch the uric acid, it just really treats the flare. Usually, we start at 100 milligrams and we increase it.
And then there is the febuxostat, which is also in the same line as allopurinol, which eliminates uric acid, and the dosing is a little different. We use a little bit less, and it has to be discussed if the patient has a history of cardiac disease.
There's the old Probenecid. We don't use it as much in rheumatology anymore unless we can actually use it in combination. It's a very weak medication.
And then there is the KRYSTEXXA, which is an IV infusion that is for people who have a lot of tophi, or deposit of uric acid in multiple joints that we cannot control with either allopurinol or febuxostat. But currently in the market, in rheumatology, those are the agents that we use.
C360: What challenges, possible complications, and considerations should clinicians be aware of in available agents for patients with gout?
MR: Everything has its side effects. So, we'll start with allopurinol, which is usually very well tolerated. But in patients of Asian descent, you need to send a genetic test for HLA b508 Because some Asian patients cannot tolerate allopurinol and you will have a severe type of reaction. So, if you are starting allopurinol in any patient of Asian descent, you must check genetic testing first before prescribing allopurinol. Overall, very well tolerated. Some nausea in the beginning. We use that in patients with chronic kidney disease, as well unless it's contraindicated, by the nephrologist. But usually, doses anywhere 100 to 300 to 400 mg is very well tolerated.
Febuxostat, we use in people with chronic kidney disease because it does not, per se, affect the kidney as much as allopurinol, but there is a caution and a contraindication people with heart disease where they saw people having increased risk of MIs and other problems with the heart and patients taking febuxostat, it wasn't a direct causation. We didn't know if it was just because we see a lot of heart disease in gout patients or if it was the medication. So, we use that, in patients with chronic disease that do not have a heart condition. And before starting patients with febuxostat, we always talk to the cardiologist prior to the start of the medication, but it's really good for patients with chronic kidney disease.
Krystexxa, as I said, is an IV medication. There are no contraindications for patients with chronic kidney disease, but there are contraindications for patients with heart failure who have a heart EF of less than 30. So usually, it's contraindicated in these patients. There is an increased risk of allergic reactions to the medication during the IV therapy. And we use it in a very well-controlled environment. Patients receive multiple medications prior to the Krystexxa, and we monitor the uric acid very closely because patients can develop antibodies to the IV medication. Usually, that happens when the uric acid, instead of going down, starts to go up. So then we stop, the treatment because the patient most likely will not have a reaction. But overall, those are the side effects and complications that we usually watch for with those medications.
C360: How should a patient with acute gout vs chronic gout be treated in a rheumatology setting?
MR: For acute gout, you have 2 options: Colchicine or good old prednisone. There is a contraindication to colchicine, which is any issues with allergies or kidney disease where, again, GFR is less than 30. You should not use colchicine on these patients or if they have an allergic reaction. So, you should not use colchicine, instead, you should use prednisone. The dose during those flares is a little bit different.
Using colchicine, we usually tell the patient, to take 1 medication now, then another pill in 2 hours, and then maybe another pill in 8 hours. It can give you severe diarrhea. In the old days, we would just say, take a pill every 2 hours until you have diarrhea. We don't do that anymore. We just take 2 or 3 pills in a day and then 1 pill a day or 2 pills a day, if the kidney function is intact.
Prednisone, we usually start a very high dose, about 40 for at least 3 days, and then we taper slowly over about a week. And that is how rheumatologists treat acute gout. So, colchicine or prednisone.
Or if there is a really inflamed joint, we can perform arthrocentesis, and pull the fluid out. Particularly with the knee and put some cortisone directly into the joint. So, those are the 3 ways.
For chronic gout, again, you want to keep that uric acid below 5. So you're either allopurinol or febuxostat are the ways to control chronic gout.
I have to add that when you're starting allopurinol, you have to start colchicine if indicated, if not contract indicated at the same time, because once you start treatment for chronic gout, patients will flare because you're pulling the uric acid out of the joints, and they're more likely to have severe flare from gout. So we start allopurinol alongside colchicine until the uric acid reaches 5, And then we discontinue colchicine.
C360: Is there anything else you’d like to add?
MR: I think that if you have any questions if you always don't quite understand, send them to the rheumatologist. Sometimes we have very delayed referrals either because we cannot accommodate the patient, but gout is one of our most common arthritis.
It is very, very, common in the summertime when there are barbecues and beer. Right? Diet is one of the most common and easy ways to control gout. So, usually looking at the patient's diet, an increase in seafood, an increase in red meat, and alcohol intake, those all add to the development of gout. So, I would say counsel your patients on diet. If they do drink, they need to stop and change the foods that have high purine content in them.