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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

For the Chapter in the Schwinghammer Handbook, please go to Chapter 1, Gout and Hyperuricemia.

KEY CONCEPTS

KEY CONCEPTS

  • image Treatment of hyperuricemia in the absence of a history of gout (ie, asymptomatic hyperuricemia) is not recommended.

  • image An acute gout flare can be treated effectively with short courses of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or low-dose colchicine.

  • image Initiation of a xanthine oxidase inhibitor may be considered in patients with one of the following indications for urate-lowering therapy (ULT): (a) one or more subcutaneous tophi, (b) evidence of joint damage by radiography, (c) two or more gout flares per year, (d) more than one previous gout flare but infrequent flares (less than two per year), (e) first gout flare in the presence of CKD stage 3 or greater, serum uric acid >9 mg/dL (535 µmol/L), or urolithiasis.

  • image The goal serum urate concentration when using ULT is less than 6 mg/dL [357 μmol/L].

  • image Allopurinol is the preferred ULT given its preferable safety and efficacy profile.

  • image Uricosuric drugs have limited efficacy in patients with impaired kidney function [CKD stage 3 or greater].

  • image Pegloticase should be reserved for patients in whom treatment with a xanthine oxidase inhibitor, uricosuric, and other interventions have failed to achieve the serum uric acid target, and who continue to have frequent gout flares (two or more per year) or non-resolving subcutaneous tophi.

  • image Low-dose colchicine, NSAID, or oral corticosteroid therapy should be administered to minimize the risk of acute gout attacks during the first 3 to 6 months of initiating ULT; therapy can be extended beyond this time period if gout flares persist.

  • image Uric acid nephrolithiasis should be treated with adequate hydration (2 L/day) and 30 to 80 mEq/day (mmol/day) of potassium bicarbonate or potassium citrate.

  • image Patients with hyperuricemia or a history of gouty arthritis should be evaluated for commonly associated comorbidities (eg, hypertension, diabetes, CKD, cardiovascular disease), and implement lifestyle modifications and aggressive management of risk factors (eg, weight loss, reduction of alcohol intake, control of blood pressure, glucose, and lipids).

PATIENT CARE PROCESS

Patient Care Process for Gout

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Collect

  • Patient characteristics (eg, age, sex, ethnicity)

  • Patient medical history (see Table 113-1)

  • Dietary habits that may lead to increased uric acid concentrations, including alcohol consumption, intake of high purine foods, and products containing high-fructose corn syrup

  • Current medications that may contribute to hyperuricemia (see Table 113-2)

  • Subjective report of acute gout symptoms

  • Objective data

    • Blood pressure (BP), height, weight

    • Labs including uric acid, serum creatinine (SCr)

    • Synovial fluid aspirate

Assess

  • Presence of acute gout (see Tables 113-3 and 113-5)

  • Presence of hyperuricemia (>6.8 mg/dL [404 µmol/L])

  • Indication for urate-lowering therapy (see Table 113-6)

  • Optimal therapy given the patient-specific characteristics (see Table 113-9)

  • Presence of other cardiovascular risk factors (eg, hypertension, diabetes)

Plan*

  • Drug therapy regimen, including a specific agent for the treatment of ...

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