Gout Prophylaxis

See also our records on Gout and Management of Acute 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

• 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