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Gout Prophylaxis
See also our records on Gout and Management of Acute Gout.
| Gout prophylaxis is indicated in patients who have had an attack of gout. |
Asymptomatic hyperuricaemia is NOT gout and does not warrant management with drugs. However, lifestyle modification may still be appropriate:1
- Drink alcohol sensibly
- There is a good evidence base that reducing alcohol intake to moderate levels is helpful.2
- There is a particularly strong link with beer, stout, port and fortified wines.
- Avoid dehydration
- Dietary intervention - reduction of purine-based foods
- A large longitudinal study found that increased intake of meat or seafood significantly increased the incidence of gout.
- Highest purine levels are found in heart, herring, sardines, mussels.3
- Other foods which are very rich in purines include liver, kidneys, red meat, yeast extracts, seafood (herring, sardines, and shellfish) and asparagus, beans, cauliflower, lentils, mushrooms, oatmeal and spinach.
- Soya foods are also high in purines but are less likely to lead to gout than meats and seafood.
- It is the quantity of purine-rich food consumed that is more important than the absolute purine content in each food.
- There is no evidence to support a reduction in purine-rich vegetables such as peas, beans, mushrooms or cauliflower, unless intake is extreme.4
- Weight reduction - there are no controlled trials available, but some evidence suggests a link between obesity and high uric acid levels5
- Take regular exercise
- Stop smoking
Manage risk factors
These may include:
- Drugs causing hyperuricaemia:
- Thiazides and loop diuretics
- Low dose salicylates e.g. aspirin < 1g/day, pyrazinamide, ethambutol, nicotinic acid, ciclosporin6
- Hypertension5
- Impaired renal function3
- Hyperlipidaemia, especially hypertriglyceridaemia7
- Vascular disease3
- Myeloproliferative disease8
General principles
- It is important to explain that medication is normally life long and regular monitoring is needed.
- Advise the person that allopurinol may cause acute attacks of gout just after initiating treatment, and for some weeks afterwards.
- Explain that they should start their anti-inflammatory treatment as soon as possible and not to stop their allopurinol during acute attacks.
Pharmacological management
| Manage recurrent attacks of gout by starting allopurinol after two or more attacks within a year.9 Uric acid lowering drug therapy should also be offered to patients with:1
|
- Allopurinol should never be started during an acute attack. Wait for 1-2 weeks after the attack resolves.
- Start with a low dose (50-100mg) and increase in 50-100mg increments every 2-4 weeks until serum uric acid (SUA) level is below 300 micromol/L.
- Maximum dose is 900mg daily.
- The timescale for increasing in dose may need to be slower in some patients, with frequent checks of renal function if renal function is known to be impaired.
- Co-prescribe colchicine or a low dose non-steroidal anti-inflammatory (NSAID) to prevent an attack of gout whilst initiating therapy, and continue until after hyperuricaemia has settled (usually a total of three months).
- If an acute attack develops during treatment, maintain the dose but add colchicine or NSAID.10
- If neither NSAIDs nor colchicine are tolerated, or both are contraindicated, consider low-dose oral prednisolone.3 However, it may be preferable to seek specialist advice.
Allopurinol
This drug is traditionally the first choice for long-term control of gout. 9,10
- It is not indicated for asymptomatic hyperuricaemia.10,11
- It is useful where renal function is impaired or renal stones are present.3,10
- Densitisation therapy is sometimes use in cases where the only adverse effect is a mild rash.1
- Check the SUA level and renal function every 3 months in the first year, then annually, and aim for a SUA below 300 micromol/L.
Sulphinpyrazone12
This can be used as alternative to allopurinol if toxicity occurs or as adjunct in resistant cases.
- It can be difficult to obtain and is contraindicated in renal failure and urolithiasis.
- Dose is 200-800mg/day in patients with normal renal function.
Colchicine
- Although not a urate-lowering drug per se, colchicine is sometimes prescribed at low dose in early gout - to 'buy time' in patients undergoing lifestyle modification, before a commitment to urate-lowering drugs is made.
Other options
- Low dose corticosteroids and NSAIDs have also been used to buy time, in the same ay as colchicine.11
- Probenecid has a less powerful uricosuric agent and is relatively contra-indicated in urolithiasis.
- Benzbromarone can also be used in patients with mild/moderate renal insufficiency at a dose of 50-200mg/day. However, it carries a small risk of hepatotoxicity.1
Document references
- Zhang W, Doherty M, Bardin T, et al; EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006 Oct;65(10):1312-24. Epub 2006 May 17. [abstract]
- Choi HK, Atkinson K, Karlson EW, et al; Alcohol intake and risk of incident gout in men: a prospective study. Lancet. 2004 Apr 17;363(9417):1277-81. [abstract]
- Gout; Clinical Knowledge Summaries (2007).
- Choi HK, Atkinson K, Karlson EW, et al; Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004 Mar 11;350(11):1093-103. [abstract]
- Choi HK, Atkinson K, Karlson EW, et al, Obesity, weight change, hypertension, diuretic use, and risk of gout in men: the health professionals follow-up study. Arch Intern Med. 2005 Apr 11;165(7):742-8. [abstract]
- Wood J, Gout and its management, The Pharmaceutical Journal 1999; 262(7048):808-811.
- Feldman EB, Wallace SL; Hypertriglyceridemia in Gout. Circulation. 1964 Apr;29:SUPPL:508-13.
- Yu TF, Secondary gout associated with myeloproliferative diseases. Arthritis Rheum. 1965 Oct;8(5):765-71.
- Guideline for the management of gout, British Society for Rheumatology (2007).
- Summary of Product Characteristics - Zyloric® Tablets (allopurinol), GlaxoSmithKline UK, September 2006, Electronic Medicines Compendium.
- Underwood M; Diagnosis and management of gout. BMJ. 2006 Jun 3;332(7553):1315-19.
- Summary of Product Characteristics - Anturan® Tablets (sulfinpyrazone), Amdipharm, January 2005, Electronic Medicines Compendium.
Internet and further reading
- Diet for gout patients; dietitians.co.uk - As MSWord document.
- ARC - Gout; Arthritis Research Council
- UK Gout Society
DocID: 330
Document Version: 3
DocRef: bgp24972
Last Updated: 3 Jan 2008
Review Date: 2 Jan 2009
Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.
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