William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
There are three aspects to the treatment of gout with medications. First, pain relievers such as acetaminophen (Tylenol) or other more potent analgesics are used to manage pain. Secondly, anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are used to decrease joint inflammation. Finally, medications are considered for managing the chronic underlying metabolic derangement that causes hyperuricemia and gout. This means treating the elevated levels of uric acid in the blood with medications that reduce these levels.
NSAIDs such as indomethacin (Indocin) and naproxen (Naprosyn) are effective anti-inflammatory medications for acute gout. These medications are tapered (decreased in dosage and eventually eliminated) after the arthritis resolves. Common side effects of NSAIDs include irritation of the gastrointestinal system, ulceration of the stomach and intestines, and even intestinal bleeding. People who have a history of allergy to aspirin or nasal polyps should avoid NSAIDs because of the risk of an intense allergic (anaphylactic) reaction. Colchicine (Colcrys) for acute gout is administered by mouth to reduce inflammation as well as to prevent gouty arthritis attacks while correcting hyperuricemia with medications such as allopurinol (Zyloprim) or febuxostat (Uloric). For acute attacks, it is given hourly or every two hours until there is significant improvement in pain or the patient develops gastrointestinal side effects such as severe diarrhea. For prevention, it is given once or twice daily. Other common side effects of colchicine include nausea and vomiting.
Corticosteroids such as prednisone, given in short courses, are powerful anti-inflammatory agents for treating acute gout. They can be administered orally or injected directly into the inflamed joint. Corticosteroids can be prescribed to patients who have accompanying kidney, liver, or gastrointestinal problems. Long-term chronic use of corticosteroids is discouraged because of serious long-term side effects.
In addition to medications for acute gout attacks, other drugs can be taken over prolonged periods to lower blood uric acid levels. Lowering blood uric acid levels reduces the risk of recurrent attacks of arthritis, kidney stones, and kidney disease, and also slowly dissolves hard tophi deposits. Medicines used to lower blood uric acid level work either by increasing the kidney's excretion of uric acid or by decreasing the body's production of uric acid from the purines in foods. These medicines are generally not started until after the inflammation from acute gouty arthritis has subsided because they can worsen the attack. If they are already being taken prior to the attack, they are continued and only adjusted after the attack has resolved.
Probenecid (Benemid) and sulfinpyrazone (Anturane) are medications that are commonly used to decrease uric acid blood levels by increasing the excretion of uric acid into the urine. Since these drugs can, in rare instances, cause kidney stones, they should be avoided by those patients with a history of kidney stones. These medications should be taken with plenty of fluid so as to promote the rapid passage of uric acid out of the urinary system in order to prevent kidney stone formation.
Allopurinol lowers the blood uric acid level by preventing uric acid production. It actually blocks the metabolic conversion from purines in foods to uric acid. This medication is used with caution in patients with poor kidney function, as they are at a particular risk of developing side effects, including severe rash and liver damage.
Febuxostat (Uloric) was approved by the U.S. Food and Drug Administration (FDA) for the chronic management of hyperuricemia from gout in 2009. Febuxostat has been shown to be more effective than allopurinol in preventing acute attacks of gouty arthritis and is effective in shrinking tophi deposits of uric acid in the tissues such as the fingers, elbows, and ears. Because febuxostat is not significantly metabolized by the kidneys, it may have advantages over allopurinol in patients with underlying kidney disease. While taking febuxostat, patients need to have uric acid levels and liver function blood tests monitored regularly.
Again, uric acid-lowering medications such as allopurinol and febuxostat are generally not started in patients who are having acute attacks of gout. These medications, when started during an acute attack, actually can worsen the acute inflammation. Therefore, uric acid-lowering drugs are usually instituted only after complete resolution of the acute arthritis attacks, but if patients are already taking these medications, they are maintained at the same doses during the acute attacks. In some patients, increasing the dose of uric acid-lowering medications can precipitate gout attacks. In these patients, low doses of colchicine can be given to prevent the precipitation of acute gout.
A new intravenous medication that is used to lower uric acid blood levels in certain patients with chronic gout is PEGylated uricase (pegloticase or Krystexxa). This infused medication (given every two weeks) is to be considered only for those patients with gout that has failed treatment with conventional uric acid-lowering medications as it can cause anaphylactic reactions and infusion reactions. Premedicating with antihistamines and cortisone medications can decrease the risk of these reactions.
It is essential to monitor the blood level of uric acid regularly once uric acid-lowering medications are used for optimal maintenance, as the uric acid metabolism can change over time.
Home remedies which can alleviate the symptoms of acute gout include resting and elevating the inflamed joint. Ice-pack applications can sometimes make the inflammation worse by causing more uric acid to form crystals in the involved area. Patients should avoid aspirin-containing medications, when possible, because aspirin prevents kidney excretion of uric acid.
Reviewed by Melissa Conrad Stöppler, MD on 5/31/2012
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