Septic arthritis, reactive arthritis, calcium pyrophosphate dihydrate (CPPD) deposition disease, rheumatoid arthritis.
Treatment: Gout Asymptomatic Hyperuricemia As only ~5% of hyperuricemic pts develop gout, treatment of asymptomatic hyperuricemia is not indicated. Exceptions are pts about to receive cytotoxic therapy for neoplasms. Acute Gouty Arthritis Treatment is given for symptomatic relief only since attacks are self-limited and will resolve spontaneously. Toxicity of therapy must be considered in each pt. - Analgesia
- NSAIDs: Treatment of choice when not contraindicated.
- Colchicine: generally only effective within first 24 h of attack; overdose has potentially life-threatening side effects; use is contraindicated in pts with renal insufficiency, cytopenias, LFTs >2 × normal, sepsis. PO—0.6 mg every 8 h with tapering or 1.2 mg followed by 0.6 mg in 1 h with subsequent day dosing depending on response.
- Intraarticular glucocorticoids: septic arthritis must be ruled out prior to injection.
- Systemic glucocorticoids: brief taper may be considered in pts with a polyarticular gouty attack for whom other modalities are contraindicated and where articular or systemic infection has been ruled out.
- Anakinra and other inhibitors of interleukin-1β have been studied, but are not widely used in clinical practice.
Uric Acid-Lowering Agents Indications for initiating uric acid-lowering therapy include recurrent frequent acute gouty arthritis, polyarticular gouty arthritis, tophaceous gout, renal stones, prophylaxis during cytotoxic therapy. Should not start during an acute attack. Initiation of such therapy can precipitate an acute flare; in pts without contraindications consider concomitant PO colchicine 0.6 mg qd until uric acid <5.0 mg/dL, then discontinue. - Xanthine oxidase inhibitors (allopurinol, febuxostat): Decrease uric acid synthesis. Allopurinol must be dose-reduced in renal insufficiency. Both have side effects and drug interactions.
- Uricosuric drugs (probenecid, sulfinpyrazone): Increases uric acid excretion by inhibiting its tubular reabsorption; ineffective in renal insufficiency; should not be used in these settings: age >60, renal stones, tophi, increased urinary uric acid excretion, prophylaxis during cytotoxic therapy.
- Pegloticase: Recombinant uricase that lowers uric acid by oxidizing urate to allantoin. Risk of severe infusion reactions. Should be used only in selected pts with chronic tophaceous gout refractory to conventional therapy.
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