Best Medication For Gout Flare Up

Who Can And Can’t Take Colchicine

Colchicine can be taken by most adults aged 18 and over.

It can sometimes be prescribed for children by a specialist doctor.

Colchicine is not suitable for some people. To make sure it’s safe for you, tell your doctor if you:

• have ever had an allergic reaction to colchicine or any other medicines
• have a severe blood disorder
• have severe kidney or liver problems
• have problems with your heart or digestive system
• are pregnant, think you might be pregnant or are trying for a baby

Women who could become pregnant will usually only be prescribed colchicine if they are using suitable contraception.

Risk Factors For Gout

Gout is more likely to occur in:

• Men. Men have a seven to nine times higher risk of gout than women, although the risk increases for women after menopause
• People with a diet high in purine-rich foods such as red meat, organ meats , seafood . Processed foods , refined carbohydrates and beverages high in fructose or sucrose also contribute to gout
• Certain ethnicities
• People who overindulge in alcohol, particularly beer and spirits
• People with certain medical conditions , and with some medications or treatments .

What To Do After A Gout Flare

While its possible to have an isolated gout attack, normally once gout strikes youll need prolonged therapy to manage it, says Dr. Saag. If you dont take regular uric-acid lowering medication or find another way to get your uric acid levels down cutting back on alcohol, losing weight, and cutting back on high-purine foods may make a difference over time you will likely experience shorter intervals between gout flares, he explains. Gout ultimately becomes a chronic arthritis, and it can be quite disabling.

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Gout Attacks: Pain Relief

Gout attacks are one of the most painful joint problems. Anti-inflammatory painkillers and steroids can help relieve the pain. The gout medication colchicine is another option but it has a slower effect.

Gout is caused by high uric acid levels. If the amount of uric acid in the body is too high, crystals may start to form in the joints and cause a painful gout attack. The pain and swelling are usually at their worst 6 to 12 hours after an attack starts. It usually takes about a week for the swelling to go down and the joint to recover. Acute pain can be relieved with anti-inflammatory painkillers or short-term steroid treatment. These medications start working within one hour.

Treatment For Gout Aims To Reduce Pain And Inflammation As Quickly And Safely As Possible

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There are several treatment options for gout. Your doctor will help you find the regimen thats right for you.

If you have a history of gout, its important to keep the right medication on hand in case of a flare-up.

Prompt treatment will help reduce the pain and the severity of the attack. It will also help to prevent damage to your joints.

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Practice Mindfulness And Meditation

The good news: A gout attack is self-limited and will clear in time. In the meantime, according to the Arthritis Foundation, meditation, yoga breathing, mindfulness, and guided imagery can help you deal with the pain.

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Which Joints Are Involved In Gouty Arthritis And Why Is It Most Common In The Foot

As with all other known types of arthritis, Gout has particular joints it tends to attack, and the foot is its most common location. Gout especially favors the bunion joint, known as the first metatarsophalangeal joint , but the ankle, midfoot and knee are also common locations, as is the bursa that overlies the elbow.

The bunion joint is the first joint involved in 75% of patients and is ultimately involved in over 90% of those with this condition. . It is thought that this joint is especially involved in gout because it is the joint that receives the highest pounds per square inch of pressure when walking or running.

Late in gout, if untreated, multiple joints can be involved, including the fingers and wrists. The shoulder joint is very rarely involved by gout and the same is true of the hip.

Figure 5: Location of Gout Attacks

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The Role Of Medication In Prevention Of Gout

Table 3: Medications to pevent attacks of gout

Standard medications in preventing gout attacks

i. Colchicine : using the matches analogy discussed above1, using colchicine can be seen as dampening the uric acid matches. Colchicine does not lower the bodys store of uric acid, but it decreases the intensity of the bodys inflammatory reaction to these crystals. Recent studies have shown that at least one mechanism of colchicines action is by acting to prevent a cascade of reactions that lead to the production of interleukin 1-beta, which is an inflammatory protein , which is important in gouty inflammation.8

ii. Allopurinol: This agent is presently the most commonly used drug for the prevention of gout. Allopurinol blocks the enzyme xanthine oxidase, which blocks the breakdown of purines, thus decreasing the bodys total amount of uric acid. Allopurinol is effective in preventing gout no matter what the mechanism of the elevated uric acid was. Whether a person is making too much uric acid, or has difficulty excreting it via the kidney, allopurinols decrease in uric acid production leads to the same goal: a decreased total body uric acid.

Table 4: Reasons to use medication to lower uric acid

Pathophysiology And Risk Factors

• References

Genetic mutations may be associated with overproductionor more often underexcretionof uric acid because of defects in the renal urate transporter system.6 The prevalence of gout increases with age and peaks at more than 12% in persons older than 80 years.1 Because female sex hormones increase urinary excretion of uric acid, pre-menopausal women have a substantially lower prevalence of gout compared with men .6 Black persons have a higher risk.7 Consuming alcoholic drinks , meat , some seafood , fruit juice, and beverages sweetened with high-fructose corn syrup increases the risk of gout.8,9 Purine-rich foods such as nuts, oatmeal, asparagus, legumes, and mushrooms do not seem to increase the risk.10 Consumption of dairy products appears to confer slight protection from gout10 .

Diuretic use*

*Adjusted for age.

Adapted with permission from Roddy E, Doherty M. Epidemiology of gout. Arthritis Res Ther. 2010 12:223, with additional information from reference 12.

Diuretic use*

*Adjusted for age.

Adapted with permission from Roddy E, Doherty M. Epidemiology of gout. Arthritis Res Ther. 2010 12:223, with additional information from reference 12.

Hard nodules on distal digit.

• References

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How Is It Taken

Allopurinol is taken as a tablet once a day. It is usually better to take it just after eating and the tablet should be swallowed with water. It is important to drink plenty of water during the day because this will help you get rid of more urate through your kidneys.

Your dose of allopurinol may change over time, depending on the amount of urate in your body. Your doctor will monitor your urate levels with blood tests every 2-4 weeks, until they are sure that the dose that youre taking is high enough to reduce the amount of urate in your body.

You may need to remain on a lower dose if you have kidney or liver problems.

Your doctor may recommend that you do not start taking allopurinol until after an attack of gout has passed to avoid triggering further attacks. If this is not possible, it may be started when your inflammation is not too bad.

Allopurinol doesnt treat the immediate pain caused by attacks of gout. But its a long-term treatment to get rid of the urate crystals which causes gout attacks.

It is likely that you will need to take allopurinol for the rest of your life to manage your urate levels. You should keep taking allopurinol even if:

• you are experiencing more gout attacks, or it doesnt seem to help the pain and inflammation at first
• you stop having gout attacks stopping your treatment can cause urate crystals to form again, which will lead to more gout attacks.

• etoricoxib

Causes Of Gout Flares

Gout, a type of inflammatory arthritis, happens when levels of uric acid a normal byproduct of metabolic reactions in your body become too high, says Kenneth Saag, MD, professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama at Birmingham. When this substance cant be sufficiently dissolved and excreted in the urine, it starts to crystallize, and those crystals deposit themselves in joints where they cause severe inflammation.

Certain risk factors, such as having a family history/genetic predisposition or having chronic kidney disease, can affect the development of gout over time. Taking certain medications , a high alcohol or sugar intake, or eating high-purine foods can trigger a gout flare. Read more about what causes gout here.

If youre new to gout, your doctor will need to confirm the diagnosis, as it can sometimes masquerade as other ailments that impact the joints . Your doctor will likely use a needle to remove some fluid from the swollen joint, then examine it under a microscope to confirm that it contains uric acid crystals.

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How To Treat A Gout Flare

Different medications can be used to address gout, but when youre in the midst of a gout flare, the number-one goal is pain management. Because the pain is so severe, its really important to try to bring it under control quickly, says Dr. Saag.

Even though gout is caused by uric acid buildup, now is not the time to start a drug thats specifically designed to lower uric acid levels.

Instead, your doctor will likely prescribe a higher dose of a non-steroidal anti-inflammatory drug , such as naproxen, or a steroid medication like prednisone. Your doctor might also inject a steroid directly into the affected joint, or, if the pain is bad enough, start you on an intravenous version of it, says Dr. Saag.

Colchicin is another medication that is sometimes used to manage gout flares. This drug is not a traditional pain reliever, since it doesnt seem to relieve pain caused by other conditions. According to a Cochrane Review, about 40 out of 100 people who use colchine during a gout attack rated their pain 50 percent lower than those who took a placebo, but theres also a high risk of side effects like vomiting, nausea, and diarrhea, especially when taken at high doses.

If youve had gout flares before and are now seeing a new provider or are being treated in the emergency room, be sure to tell the doctor about the treatments youve previously tried during an acute episode and how well they worked for you.

Medication Options For Uric Acid Lowering

It is important to note that whenever starting a uric acid lowering treatment, there is a risk of precipitating a gout flare. A plan should be in place for management if this occurs. This generally can be avoided with the co-administration of prophylactic medications along with the uric acid lowering therapy.

Probenecid

Probenecid may be given to patients with decreased clearance of uric acid by the kidney and normal renal function. In general its use should be limited to patients under the age of 60. Probenecid acts by inhibiting reabsorption of uric acid in the proximal tubules of the kidney. Starting dose is at 500 mg to 1000 mg daily and increased to 1500 mg to 2000 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 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.

• uricosuric
• useful in patients with decreased renal clearance of uric acid
• can only be used if creatinine clearance > 40 cc/min
• must have 24 hour urine for uric acid < 800 mg/dl
• can be used in renal failure
• increased risk of renal stones

Allopurinol

Pegloticase

• pegylated porcine uricase

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The Relation Of Uric Acid And Ult To Kidney Outcomes

CKD leads to hyperuricemia due to decreased urinary excretion of UA. Hyperuricemia also may induce kidney dysfunction and contribute to CKD progression through a number of potential mechanisms. It is possible that controlling hyperuricemia, especially if achieved early, may reduce kidney disease risk.

Medications To Prevent Gout Flare

It is important to prevent gout from flaring up in the first place! Finding the right drug to help with this is essential.

Options include:

Xanthine oxidase inhibitors

Xanthine oxidase inhibitors limit the amount of uric acid the body produces, thus reducing the amount of uric acid in the body.

• Allopurinol is the most widely used gout medication. What is the downside to this medication? It can take three to six months before it starts to work meaning that when it is initially prescribed, another flare-up can occur before it has begun to work. This doesnt mean that it isnt working, it just hasnt had the time to reach its full potential. It is started at a low dose and increased every two to four weeks until reaching the full dose.
• is similar to allopurinol in function, it is safer to use for people with kidney disease. However, it does have a higher risk of blood clots.

Probenecid

Probenecid allows the body to remove uric acid from the body more effectively.

Although this lowers the uric acid levels in the body, it increases the uric acid levels in the urine which increases the chances of developing kidney stones. This medication is contraindicated in people with kidney disease.

Lesinurad

Lesinuard has a complex mechanism of action.

Meaning it must be used in combination with allopurinol or febuxostat at all times.

• Gout Foot Pain

Pegloticase

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How Much Will I Take

For gout

The usual dose is 1 tablet , taken 2 to 4 times a day.

You’ll usually take colchicine for just a few days. Your doctor will tell you how long to take it for.

For familial Mediterranean fever

Doses can vary between 1 and 4 tablets , taken once a day.

Your doctor will probably recommend taking this medicine long-term.

How Is Gout Diagnosed

In a clear-cut case, a primary care physician can make the diagnosis of gout with a high level of confidence. However, often there are two or more possible causes for an inflamed toe or other joint, which mimics some of the symptoms of gout, so tests to identify the presence of uric acid is performed.

Since the treatment for gout is lifelong, its very important to make a definitive diagnosis. Ideally, the diagnosis is made by identifying uric acid crystals in joint fluid or in a mass of uric acid . These can be seen by putting a drop of fluid on a slide and examining it using a polarizing microscope, which takes advantage of the way uric acid crystals bend light. A non-rheumatologist, when possible, can remove fluid from the joint by aspirating it with a small needle and send it to a lab for analysis. A rheumatologist is likely to have a polarizing attachment on their microscope at their office. Gout crystals have a needle-like shape, and are either yellow or blue, depending on how they are arranged on the slide .

Figure 11: Uric Acid Crystals Under Polarizing Light Microscopy

There are many circumstances where, however ideal it would be, no fluid or other specimen is available to examine, but a diagnosis of gout needs to be made. A set of criteria has been established to help make the diagnosis of gout in this setting .2

Table 1: Diagnosing gout when no crystal identification is possible

Ideally, 6 of 10 features will be present of the following:

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How Can A Gout Attack Be Prevented

Diet plays a key role diet in gout prevention: Since foods can directly set off gout attacks, patients with gout should receive counseling as to which foods are more likely to induce attacks. Losing weight is often also helpful. However, as important as diet is in gout, for most people with gout diet, and even weight loss, are not enough, and medications will be needed to get to their uric acid goal.

Drink Plenty Of Water

This wont likely provide immediate relief, but inadequate hydration is known to contribute towards the creation of urate crystals.

Drinking water may flush uric acid crystals out of your system.

Preliminary research suggests that adequate water consumption during the 24-hour period before a gout flare can decrease recurrent gout attacks.

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