Uricosuric agents are alternative therapies in patients with preserved renal function and no history of nephrolithiasis. When initiating urate-lowering therapy, concurrent prophylactic therapy with low-dose colchicine for three to six months may reduce flare-ups.
Gouty arthritis accounted for an estimated 3. However, data indicate that even with universal health care coverage, quality of treatment may be suboptimal in up to one half of patients with gout.
Recent insurance claims data show that the prevalence increased annually by two cases per 1, persons between and C Nonsteroidal anti-inflammatory drugs, corticosteroids, and colchicine are effective treatments for acute gout. B In patients with gout, modifiable risk factors such as obesity, diuretic use, high-purine diet, and alcohol intake should be addressed. Starting dose is at mg to mg daily and increased to mg to mg as needed. Occasionally higher doses are needed.
Probenecid may precipitate renal stone formation and good oral hydration should be encouraged. Probenecid is contraindicated in patients with renal stones including calcium and uric acid stones and in patients with urate nephropathy. Probenecid given inappropriately to patients with hyperuricemia due to overproduction of uric acid can cause renal stones and urate nephropathy. Toxicites include rash, hepatoxicity, bone marrow suppression and severe hypersensitivity reactions.
Medication interactions can occur with allopurinol, warfarin, and theophylline and levels should be monitored. Because long-term use of corticosteroids can lead to several side effects, and in particular worsening of diabetes, the risk—benefit ratio should be evaluated regularly once treatment has begun.
Canakinumab has been approved by the European Medicines Agency for the symptomatic treatment of frequent acute GFs in patients in whom NSAIDs and colchicine are contraindicated, are not tolerated or do not provide an adequate response and in whom repeated courses of corticosteroids are not appropriate.
The agent is not approved for prophylaxis for GFs. Of note, the US Food and Drug Administration has not approved canakinumab for either prophylaxis or the treatment of flares, mainly because of safety concerns. In a phase 2 trial, Schlesinger et al. At 16 weeks the mean number of flares per patient was 0.
No evidence for a dose response for canakinumab was seen. The tolerance was similar in each group, but more infections were observed in the canakinumab groups.
Canakinumab should not be administered during an active infection and physicians should exercise caution when administering it to patients with underlying conditions that may predispose them to infections. Other side effects reported with canakinumab are neutropenia and injection site reactions. In each trial a loading dose of rilonacept was initially administered, which was twice the dose administered weekly thereafter.
The mean number of flares per patient at week 12 was significantly lower in the rilonacept than the placebo group 0. This beneficial effect occurred early and was maintained throughout the trial. The rate of adverse events was similar between groups. In both studies the treatment was administered for 16 weeks and the primary outcome was the number of flares per patient through week In the first trial [ 23 ], of patients, the mean number of flares per patient was significantly reduced in both rilonacept groups [1.
In the second trial [ 8 ], the mean number of flares per patient was reduced by In these studies, the rate of adverse events was similar between groups, except for a higher risk of reaction at the injection site with rilonacept [ 8 , 23 ]. The positivity of these antibodies was associated with higher injection site reaction rates [ 8 ].
The other most frequently reported adverse events were upper respiratory tract infection including influenza viral infections and headache. Rilonacept is not approved as prophylactic treatment for acute gout. Overall, IL-1 blockers seem to have a relatively good safety profile for short-term use and showed satisfactory efficacy in the prophylaxis of acute GFs. They could be good candidates as alternative therapy to colchicine, NSAIDs or corticosteroids in situations of contraindication or intolerance to these drugs.
Their cost and their putative infectious adverse events [ 44 ] preclude their use as a first-line prophylactic option. Conclusions Considering prophylaxis for acute GFs is critical in the management of gout because it may help to enhance adherence to ULT, which can cure gout, if taken appropriately.
The currently recommended drugs [ 2 , 18 ] for prophylaxis are those used to treat acute gout, but at a lower dosage. We lack data comparing their efficacy.
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© Copyright 2017 Gout prophylaxis with colchicine. Gout: An Update.