Gout is a form of arthritis, causing intensely painful, red, hot and swollen joints often the big toe. Learn about the causes, symptoms and treatments. Allopurinol is often recommended as the first choice of treatment to control gout. If your doctor prescribes it as soon as you are diagnosed, it may prevent future attacks and joint damage. You will usually be offered allopurinol if blood tests show that your urate level is high enough for urate crystals to form, especially if one or more of the following applies:.
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 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. 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:. To reduce the effects of gout attacks in the first three to six months of taking allopurinol, your doctor may prescribe a low dose of colchicine or a non-steroidal anti-inflammatory drug NSAID , such as:. You should be offered another tablet, known as a proton pump inhibitor, to protect your stomach while taking NSAIDs.
Most people who take allopurinol do not get any serious side effects. However, some side effects of allopurinol include:. If you develop a rash, redness or flu-like symptoms, you should contact your doctor straight away. If you become dizzy or drowsy while taking allopurinol, do not drive or operate machinery, and see your doctor as soon as possible. You should also speak to your doctor if you develop any new symptoms that worry you.
Sometimes starting allopurinol can trigger a gout attack. This is because some of the crystals can dislodge into the joint as they get smaller which can cause an attack. You may be given another medicine to reduce the risk of these attacks. Very rarely, allopurinol can lower the number of blood cells that fight infection in your body. This is called allopurinol hypersensitivity syndrome. This mainly occurs in people who have chronic kidney disease and have started a higher dose of allopurinol.
Needle-shaped crystals form in and around joints — often beginning in the base of the big toe — causing episodes of severe pain, heat and swelling. In people with gout who have tophi hard lumps of uric acid crystals that can be seen under the skin , doctors want uric acid levels even lower.
If it can be maintained in the target range, uric acid crystals dissolve, gout flares are reduced or eliminated and tophi shrink. Last year, an international panel of gout experts published recommendations that doctors use a treat-to-target approach for managing gout.
But around the same time, the American College of Physicians a national organization of internal medicine physicians published its own guidelines for gout treatment recommending against long-term use of uric acid-lowering medication in patients with infrequent flares until more research is available.
Some of that research may now be available. The new study, published recently in Annals of the Rheumatic Diseases , suggests doctors can safely increase doses of the gout drug allopurinol to help reach those targets. The safety of these higher doses is particularly important for the many people with gout who also have chronic kidney disease or other health conditions.
Allopurinol is the most commonly used uric acid-lowering drug, but many doctors are hesitant to use it at doses needed to achieve target serum urate levels for fear of side effects, explains Lisa Stamp, PhD, lead study author and professor of medicine at University of Otago in Christchurch, New Zealand.
To determine the safety and effectiveness of increasing doses of allopurinol in real-world circumstances, Stamp and her colleagues undertook a dose-escalation study. The study followed people with gout. More than half the participants had reduced kidney function a common problem among people with gout and 44 percent had severe gout as determined by the presence of tophi. All participants had been taking allopurinol for at least one month when the study began. The American College of Rheumatology recommends:.
This recommendation is in recognition that even after the target serum urate level has been reached, flares may continue to occur for some time. Once target serum urate has been reached, six-monthly monitoring by testing serum urate is recommended to ensure continuing adequate management and adherence.
Adherence with long-term allopurinol is poor and every effort should be made to encourage patients to continue to take it, including involving family members. Febuxostat is a newer agent used to treat gout that works by inhibiting xanthine oxidase — the same mechanism as allopurinol. One approach is to start the patient on a very low dose of allopurinol eg 1.
Research has suggested that patients with gout who lack confidence in their treatments have reduced adherence to their medications. A lack of confidence in treatment can result from their gout flaring after initiation of urate-lowering therapy. A large intake of sugar or sweetened soft drinks, such as cola or lemonade, is a recognised risk for gout. Patients with gout are advised to limit their intake of these beverages. Although epidemiological evidence suggests that a high-purine diet increases the risk of gout, there is scant evidence that introducing a low-purine diet in those with gout results in a clinically meaningful reduction in gout flares or serum urate.
A comprehensive approach is best, including providing patients with a schema to help them understand important aspects of gout management Box 1. The increasing prevalence and impact of gout mean that greater focus is required to ensure best outcomes for patients. Newer therapeutic agents are on the horizon, but gout can still be well treated with our current agents, especially in light of recent insights into treatment strategies, such as commencing allopurinol during acute attacks and starting at a low dose and titrating up.
Competing interests: Philip C Robinson has received research funding and consulting fees from AstraZeneca, and consulting fees from Menarini and Novartis. Lisa K Stamp has received consulting fees from AstraZeneca. Provenance and peer review: Not commissioned, externally peer reviewed. Australian Family Physician. Search for: Search AFP. Filter Relevance Date. Issues by year. Volume 45, Issue 5, May Background Gout is a common problem that is increasing in prevalence in Australia.
It is associated with many serious comorbidities such as hypertension, chronic kidney disease, obesity, diabetes and cardiovascular disease. Recent changes include the way that older drugs are used, as well as newer therapeutics becoming available or in development. Objective The objective of this article is to provide an update on the management of gout. Discussion Developments in treatment strategies for gout and newer agents to treat gout are discussed in this article.
The salient points include the need to treat gout to a serum urate target, the ability to start allopurinol during acute attacks, the need to treat with prophylactic anti-inflammatory drugs for adequate time periods, and the availability of a new urate-lowering drug on the Pharmaceutical Benefits Scheme PBS. Common misconceptions Gout does not occur only in the great toe podagra , although this is a common site for the initial episode.
Gout growing in prevalence and impact Gout has often been viewed as a nuisance and non-serious condition. There are treatments that: 1,7 raise serum urate eg thiazide, loop diuretics impair the actions of urate-lowering drugs eg frusemide lower serum urate eg losartan. Treat to target Treating patients to a target serum urate is essential for reducing gout flares and resolving tophi.
Acute flare treatment Treatment of acute flares should begin as soon as possible. Allopurinol can be started during an acute attack Historically, there has been concern that starting urate-lowering therapy such as allopurinol could worsen or prolong the acute gout flare. Allopurinol needs to be started low and up-titrated Evidence suggests that it is the starting dose of allopurinol, not the maintenance dose, that increases the risk of allopurinol hypersensitivity syndrome AHS.
Monitoring of serum urate Once target serum urate has been reached, six-monthly monitoring by testing serum urate is recommended to ensure continuing adequate management and adherence. Febuxostat as an alternative urate-lowering therapy Febuxostat is a newer agent used to treat gout that works by inhibiting xanthine oxidase — the same mechanism as allopurinol. Patient education Research has suggested that patients with gout who lack confidence in their treatments have reduced adherence to their medications.
Box 1. Gout treatment schema 23 Set urate target Start urate-lowering therapy with prophylaxis Ensure patient has acute flare plan see text for further details Monitor serum urate until target reached Titrate urate-lowering therapy to achieve target Once target achieved, monitor 6—12 monthly Treatment of asymptomatic hyperuricaemia No current guidelines or recommendations in the US, UK, Australia or New Zealand support treatment of asymptomatic hyperuricaemia.
Conclusion The increasing prevalence and impact of gout mean that greater focus is required to ensure best outcomes for patients. Gout: Joints and beyond, epidemiology, clinical features, treatment and co-morbidities. Maturitas ;78 4 — An observational study of gout prevalence and quality of care in a national Australian general practice population. J Rheumatol ;42 9 — Systematic review of the prevalence of gout and hyperuricemia in Australia.
Intern Med J ;42 9 — Global epidemiology of gout: Prevalence, incidence and risk factors. Nat Rev Rheumatol ;11 11 — The impact of gout on work absence and productivity.
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