Materiały źródłowe

• #1 Urate-Lowering Therapy for the Prevention and Treatment of Gout Flare

  https://www.uspharmacist.com/article/uratelowering-therapy-for-the-prevention-and-treatment-of-gout-flare

  Gout is one of the most common rheumatologic arthritic diseases in the United States. Preventing future gout attacks requires lowering serum urate levels to promote dissolution of urate crystals, which is accomplished by reducing the production of serum uric acid or promoting its excretion. Xanthene oxidase inhibitors (XOIs), including allopurinol and febuxostat, are first-line agents for the prevention of acute attacks. Probenecid, a uricosuric agent, is an appropriate adjunctive therapy or second-line agent when XOIs are contraindicated or poorly tolerated. […] Management of gout falls into two categories: treatment of acute gout attacks and prophylaxis of gout flares. The goal of treating acute attacks is to resolve arthritic pain and inflammation. […] Prophylactic treatment of gout flare-ups consists of lowering serum urate levels by reducing the production of uric acid or increasing the excretion of urate from the body.

• #2 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Gout is typically diagnosed using clinical criteria from the American College of Rheumatology. […] To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods (e.g., organ meats, shellfish) and avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup. […] Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout, and colchicine and/or probenecid are reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective. […] Serum uratelowering therapy should be initiated to prevent recurrences in persons with a history of gout and any one of the following: at least two flares per year (one per year in persons with chronic kidney disease stage 2 or greater), tophi, or a history of nephrolithiasis.

• #3 The management of gout: Much has changed

  https://www.racgp.org.au/afp/2016/may/the-management-of-gout-much-has-changed

  Prophylaxis of acute flare of gout is recommended in those commencing on urate-lowering therapy. Gout flares on starting urate-lowering therapy are very common and prophylaxis aims to prevent them from occurring. In a trial of allopurinol where prophylaxis was ceased, a flare rate of 64% was observed. In those receiving naproxen (250 mg twice daily) or colchicine (0.6 mg daily) prophylaxis, 20-28% of patients experienced flares on initiation of urate-lowering therapy. Although no head-to-head trials have been completed, the available data suggest that flare rates are substantially reduced by anti-inflammatory prophylaxis. NSAIDs or colchicine are the first-line recommended agents. This can be achieved by a moderate dose of an NSAID, such as naproxen 250 mg twice daily, or 0.5-1 mg of colchicine per day. Consideration of medication contraindications and use of gastric protection may be appropriate.

• #4 Gout and Pseudogout Treatment & Management: Approach Considerations, Treatment of Acute Attacks, Treatment of Chronic Gout

  https://emedicine.medscape.com/article/329958-treatment

  Gout is managed in the following 3 stages: […] Providing prophylaxis to prevent acute flares […] The American College of Rheumatology (ACR) published guidelines on the treatment and prophylaxis of acute gouty arthritis and the management of hyperuricemia. […] The risk of gout flares emphasizes the importance of providing close coverage, patient education, and prophylaxis, especially during the first year of urate-lowering therapy. […] Because allopurinol, febuxostat, and probenecid change serum and tissue uric acid levels, they may precipitate acute attacks of gout. To reduce this undesired effect, colchicine or low-dose NSAID treatment is provided for at least 6 months. […] When used prophylactically, colchicine can reduce such flares by 85%. […] If the patient develops a gout flare after beginning therapy with a uric acid-lowering agent, the agent should not be discontinued, because discontinuance will only cause another flux in the uric acid level, which may prolong and intensify the attack.

• #5 Prophylaxis for acute gout flares after initiation of urate-lowering therapy – PubMed

  https://pubmed.ncbi.nlm.nih.gov/24758886/

  This review summarizes evidence relating to prophylaxis for gout flares after the initiation of urate-lowering therapy (ULT). […] According to the most recent international recommendation, the two first-line options for prophylaxis are low-dose colchicine (0.5 mg once or twice a day) or low-dose NSAIDs such as naproxen 250 mg orally twice a day. They can be given for up to 6 months. […] Prophylaxis for flares induced by ULT is an important consideration in gout management. Low-dose colchicine and low-dose NSAIDs are the recommended first-line therapies. […] Although no IL-1 blockers are approved as prophylactic treatment, this class of drug could become an interesting option for patients with gout with intolerance or contraindication to colchicine, NSAIDs or corticosteroids.

• #6

  https://www.healio.com/clinical-guidance/gout/prophylaxis-of-acute-gout-flares-assessment-and-treatment

  The goals of therapy in gout include not simply active and rapid treatment of acute gout flares but also prevention of acute gout attacks, whose major precipitating factors are listed in Table 9-1. […] A general algorithm for gout flare prophylaxis, broadly based on the clinical practice preferences of the authors of this handbook is presented in Figure 9-1. However, please note that gout flare prophylaxis should be individualized for the patient. […] For prophylaxis of acute gout, low-dose colchicine therapy or low-dose NSAID therapy is commenced 1 to 2 weeks before initiation of serum ULT and continued for at least 3-6 months (if successful serum urate lowering to target [usually 6 mg/dL] is achieved). […] The most common adverse event caused by starting ULT is precipitation of acute gout flares in the first months of therapy. In clinical practice, gout-flare prophylaxis always should be combined with a ULT program.

• #7 The management of gout: Much has changed

  https://www.racgp.org.au/afp/2016/may/the-management-of-gout-much-has-changed

  The recommended duration of prophylaxis is now longer than what has previously been used. The American College of Rheumatology recommends: at least six months duration, or three months duration after achieving target serum urate in patients without tophi, or six months duration after achieving target serum urate in patients with tophi on examination. This recommendation is in recognition that even after the target serum urate level has been reached, flares may continue to occur for some time. Every clinical scenario is different and practitioners need to carefully consider the risks and benefits when prescribing prolonged courses of acute gout flare prophylaxis.

• #8 Prophylaxis on gout flares after the initiation of urate-lowering therapy: a retrospective research

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4723937/

  The objective of this study was to evaluate the efficacy and safety associated with treatment available to prevent an acute attack of gout when initiating a urate-lowering therapy (ULT). […] In order to decrease the high rate of gout attacks early in ULT, pharmacologic anti-inflammatory prophylaxis is recommended when initiating ULT. […] The guidelines recommended, as first-line prophylactic agents, the use of either low-dose colchicine or Non-steroidal anti-inflammatory drugs (NSAID). […] Prophylaxis should be continued for 6 months after initiation of ULT. […] Our results showed that the frequency of gout attacks in etoricoxib group and colchicine group were significantly lower than that in no prophylaxis group. It indicated that prophylaxis could effectively reduce acute gout flares when ULT.

• #9 Gout Flares After Stopping Anti-inflammatory Prophylaxis During the Early Phases of Urate-Lowering Therapy – ACR Meeting Abstracts

  https://acrabstracts.org/abstract/gout-flares-after-stopping-anti-inflammatory-prophylaxis-during-the-early-phases-of-urate-lowering-therapy/

  Anti-inflammatory prophylaxis is recommended during the initial period of urate-lowering therapy (ULT) as gout flares are common during this time. […] Gout flares are common after stopping prophylaxis, irrespective of duration, but return to levels seen during prophylaxis. People with gout should be cautioned about risk of flares and have a flare management plan particularly in the three months following discontinuation of anti-inflammatory prophylaxis.

• #10 Colchicine Prophylaxis When Starting Allopurinol: A Randomized Triallogo-32logo-40logo-60NEJM Journal WatchnejmJW_1L_RGB-b

  https://www.jwatch.org/na56895/2023/12/14/colchicine-prophylaxis-when-starting-allopurinol

  Colchicine prevented gout flares, but a rebound in flares seemed to occur when it was stopped. […] Guidelines thus recommend several months of anti-inflammatory prophylaxis (e.g., with colchicine) after starting allopurinol. […] Colchicine protected against gout flares, but after it was stopped, the colchicine group “caught up” with the control group in number of flares. These findings could support either continuing low-dose colchicine prophylaxis for longer than 6 months or not giving prophylaxis at all when we use “start-low, go-slow” allopurinol dosing. Either way, patients should be prepared to start anti-inflammatory treatment at the earliest sign of a flare.

• #11 Colchicine

  https://arthritis.ca/treatment/medication/medication-reference-guide/medications/colchicine

  Colchicine is used to help treat and prevent gout attacks by stopping your immune cells from replicating and causing inflammation. […] Colchicine is used to help treat and prevent gout attacks. […] The usual dose to prevent gout attacks is: 0.6 mg once to twice daily. […] For best results colchicine should be started within 24 hours of a gout attack. […] If you are starting allopurinol your prescriber may recommend taking 0.6 mg once or twice daily for 3 to 6 months. […] Colchicine works by disrupting the ability of immune system cells to replicate. This helps to reduce inflammation and patients who take colchicine can benefit from reduced swelling and pain associated with gout attacks. […] Drinking alcohol can contribute to gout flares. It is best to avoid alcohol if you have gout.

• #12 Effectiveness of Prophylaxis with Anti-Gout Medications On Risk of Gout Attacks – ACR Meeting Abstracts

  https://acrabstracts.org/abstract/effectiveness-of-prophylaxis-with-anti-gout-medications-on-risk-of-gout-attacks/

  Effectiveness of Prophylaxis with Anti-Gout Medications On Risk of Gout Attacks […] While a few studies have examined colchicines ability to prevent gout attacks, NSAIDs have not been formally studied in this regard, despite use of naproxen and its apparent efficacy in the febuxostat trials. Little data are available on effectiveness of prophylaxis with anti-gout medications on risk of gout attacks as used in the community. […] Colchicine was effective in protecting against gout attacks when taken consistently; intermittent or short-term use did not confer protection. We cannot exclude the possibility that particular formulations and/or doses of NSAIDs are effective; nonetheless, as used in the community, NSAIDs were not associated with lower risk of gout attacks.

• #13 Prophylaxis for acute gout flares after initiation of urate-lowering therapy – PubMed

  https://pubmed.ncbi.nlm.nih.gov/24758886/

  This review summarizes evidence relating to prophylaxis for gout flares after the initiation of urate-lowering therapy (ULT). […] According to the most recent international recommendation, the two first-line options for prophylaxis are low-dose colchicine (0.5 mg once or twice a day) or low-dose NSAIDs such as naproxen 250 mg orally twice a day. They can be given for up to 6 months. […] Prophylaxis for flares induced by ULT is an important consideration in gout management. Low-dose colchicine and low-dose NSAIDs are the recommended first-line therapies. […] Although no IL-1 blockers are approved as prophylactic treatment, this class of drug could become an interesting option for patients with gout with intolerance or contraindication to colchicine, NSAIDs or corticosteroids.

• #14 ACR GUIDELINES Bundle (free trial) – Gout Hyperuricemia

  https://eguideline.guidelinecentral.com/i/631809-gout-hyperuricemia/7

  Treatment 3 Figure 4. Pharmacologic Antiinflammatory Prophylaxis of Gout Attacks Evaluate gout symptoms while on ULT Continue pharmacologic anti- inflammatory prophylaxis Continued activity of gout signs/symptoms d No signs/symptoms Duration of Prophylaxis: Treatment for the greater of: • At least 6 months (A) OR • 3 months after achieving target serum urate appropriate for the patient (B) (No tophi detected on physical exam) • 6 months after achieving target serum urate appropriate for the patient (C) (One or more tophi detected on physical exam) […] Initiate Prophylaxis: • Concurrent with, or just prior to, initiation of ULT • Medication choices Low dose colchicine a : Low dose colchicine, 0.6 mg once or twice daily (Outside US: 0.5 mg once or twice a day) (A) OR Low dose NSAIDs: with proton pump inhibitor (where indicated) e.g., naproxen 250 mg twice daily (C) Alternate treatment b : Low dose prednisone or prednisolone c (≤10 mg/day) (C) (Most practical for patients on chronic low dose steroids –e.g., transplant patients, low dose steroids as alternate only if colchicine and NSAIDs contraindicated or ineffective. Limit duration of low dose steroids.)

• #15 ACR GUIDELINES Bundle (free trial) – Gout Hyperuricemia

  https://eguideline.guidelinecentral.com/i/631809-gout-hyperuricemia/7

  Treatment 3 Figure 4. Pharmacologic Antiinflammatory Prophylaxis of Gout Attacks Evaluate gout symptoms while on ULT Continue pharmacologic anti- inflammatory prophylaxis Continued activity of gout signs/symptoms d No signs/symptoms Duration of Prophylaxis: Treatment for the greater of: • At least 6 months (A) OR • 3 months after achieving target serum urate appropriate for the patient (B) (No tophi detected on physical exam) • 6 months after achieving target serum urate appropriate for the patient (C) (One or more tophi detected on physical exam) […] Initiate Prophylaxis: • Concurrent with, or just prior to, initiation of ULT • Medication choices Low dose colchicine a : Low dose colchicine, 0.6 mg once or twice daily (Outside US: 0.5 mg once or twice a day) (A) OR Low dose NSAIDs: with proton pump inhibitor (where indicated) e.g., naproxen 250 mg twice daily (C) Alternate treatment b : Low dose prednisone or prednisolone c (≤10 mg/day) (C) (Most practical for patients on chronic low dose steroids –e.g., transplant patients, low dose steroids as alternate only if colchicine and NSAIDs contraindicated or ineffective. Limit duration of low dose steroids.)

• #16 Prophylaxis for acute gout flares after initiation of urate-lowering therapy – PubMed

  https://pubmed.ncbi.nlm.nih.gov/24758886/

  This review summarizes evidence relating to prophylaxis for gout flares after the initiation of urate-lowering therapy (ULT). […] According to the most recent international recommendation, the two first-line options for prophylaxis are low-dose colchicine (0.5 mg once or twice a day) or low-dose NSAIDs such as naproxen 250 mg orally twice a day. They can be given for up to 6 months. […] Prophylaxis for flares induced by ULT is an important consideration in gout management. Low-dose colchicine and low-dose NSAIDs are the recommended first-line therapies. […] Although no IL-1 blockers are approved as prophylactic treatment, this class of drug could become an interesting option for patients with gout with intolerance or contraindication to colchicine, NSAIDs or corticosteroids.

• #17 Canakinumab Prophylaxis Resolves Active Gout Flares Within 48 Hours

  https://www.hcplive.com/view/canakinumab-prophylaxis-resolves-active-gout-flares-within-48-hours

  Administering canakinumab prophylaxis before a pegloticase infusion prevents new gout glares induced by pegloticase + methotrexate treatment. […] Canakinumab prophylaxis resolves active gout flares within 48 hours and prevents new gout flares among patients initiating pegloticase + methotrexate, according to a study presented at the 2024 European Alliance of Associations for Rheumatology (EULAR) in Vienna, Austria. […] Prophylaxis using a single dose of canakinumab 150mg prevented gout flares in all patients initiating pegloticase + methotrexate for uncontrolled gout without corticosteroids and did not compromise efficacy or safety, investigators concluded. Although additional studies are needed to corroborate these results, this data supports prophylaxis with canakinumab instead of corticosteroids when initiating pegloticase + methotrexate treatment.

• #18 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Serum urate should be lowered to a target of less than 5 to 6 mg per dL (297 to 357 mol per L), depending on the crystal and tophaceous burden. […] Weight gain is a significant risk factor for gout in men, whereas weight loss reduces the risk. […] Intake of high-fructose corn syrup should be restricted because the fructose contributes to increased uric acid production as a byproduct of adenosine triphosphate catabolism. […] Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). […] Pharmacologic options for prevention of chronic gout are outlined in Table 4. […] Although avoidance of loop and thiazide diuretics has been recommended for patients with hypertension and gout because these agents can increase uric acid levels, a systematic review found only small increases in the risk of gouty flares. […] Losartan is the only angiotensin receptor blocker with this property.

• #19

  https://bpac.org.nz/2021/gout-part1.aspx

  Gout management in New Zealand needs to change because Mori and Pacific peoples in particular are not receiving the medicines according to their level of need. […] Once urate-lowering medicines are started, monitoring is also often sub-optimal, meaning that many patients will still have serum urate concentrations above recommended levels for treating gout. […] Most patients with gout are able to achieve serum urate targets if they are provided with effective support. […] Urate-lowering treatment should be discussed with all patients with gout once a diagnosis has been established. […] Patients with symptomatic hyperuricaemia and any of the following should start urate-lowering treatment: Two or more flares per year, tophi or erosions on X-ray, renal impairment, past urolithiasis, serum urate level 0.54 mmol/L. […] Regular use is the key to long-term management. […] Rongo rkau (traditional plant remedies with healing properties) may be used by some Mori patients to treat flares of gout. Urate-lowering medicines can be used safely in combination with Rongo rkau and should not be discouraged.

• #20 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Gout is typically diagnosed using clinical criteria from the American College of Rheumatology. […] To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods (e.g., organ meats, shellfish) and avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup. […] Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout, and colchicine and/or probenecid are reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective. […] Serum uratelowering therapy should be initiated to prevent recurrences in persons with a history of gout and any one of the following: at least two flares per year (one per year in persons with chronic kidney disease stage 2 or greater), tophi, or a history of nephrolithiasis.

• #21

  https://bpac.org.nz/2021/gout-part1.aspx

  Gout management in New Zealand needs to change because Mori and Pacific peoples in particular are not receiving the medicines according to their level of need. […] Once urate-lowering medicines are started, monitoring is also often sub-optimal, meaning that many patients will still have serum urate concentrations above recommended levels for treating gout. […] Most patients with gout are able to achieve serum urate targets if they are provided with effective support. […] Urate-lowering treatment should be discussed with all patients with gout once a diagnosis has been established. […] Patients with symptomatic hyperuricaemia and any of the following should start urate-lowering treatment: Two or more flares per year, tophi or erosions on X-ray, renal impairment, past urolithiasis, serum urate level 0.54 mmol/L. […] Regular use is the key to long-term management. […] Rongo rkau (traditional plant remedies with healing properties) may be used by some Mori patients to treat flares of gout. Urate-lowering medicines can be used safely in combination with Rongo rkau and should not be discouraged.

• #22 Allopurinol | Side-effects, uses, time to work

  https://versusarthritis.org/about-arthritis/treatments/drugs/allopurinol/

  Allopurinol is used for the long-term treatment and prevention of gout. Taken regularly, it can stop attacks of gout and help prevent damage to your joints. […] Allopurinol works by lowering the amount of urate in your blood. Because of this, its sometimes called a urate lowering therapy (ULT). Once your urate level is low enough, new crystals will stop forming and existing crystals will slowly dissolve. […] 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. […] Allopurinol doesn’t treat the immediate pain caused by attacks of gout. But it’s a long-term treatment to get rid of the urate crystals which causes gout attacks. […] 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).

• #23 Gout Treatment Guidelines | Arthritis Foundation

  https://www.arthritis.org/diseases/more-about/gout-treatment-guidelines

  Treating gout with urate-lowering medications is strongly recommended for patients who have tophi (nodules that form from a mass of uric acid crystals at joints or in soft tissues), radiographic evidence (X-ray or other imaging) of damage due to gout, or two or more gout flares per year. […] Allopurinol is strongly recommended as a first-line urate-lowering medication over all others for all patients. […] Using anti-inflammatory medication, such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone or prednisolone as a preventive measure along with urate-lowering meds is strongly recommended over not using anti-inflammatory meds. […] Using treat-to-target strategy by adjusting urate-lowing meds to reach a target uric acid level of less than 6 mg/dl (milligrams per deciliter) is strongly recommended over using a fixed dose of the medication and no target. […] Limiting consumption of alcohol, purines and high-fructose corn syrup are conditionally recommended. […] Using some weight-loss program is conditionally recommended for gout patients who are overweight or obese.

• #24 Allopurinol | Side-effects, uses, time to work

  https://versusarthritis.org/about-arthritis/treatments/drugs/allopurinol/

  Allopurinol is usually the first urate lowering therapy (ULT) recommended for gout. But if you’re unable to continue taking allopurinol because of the side effects, you may be able to take another drug instead, such as febuxostat, which works in a similar way to allopurinol. […] Allopurinol can be continued when you have surgery but, your doctor may recommend that you temporarily stop allopurinol and then restart it again 5-7 days later at the same dose.

• #25 Gout – Wikipedia

  https://en.wikipedia.org/wiki/Gout

  It is not until this point that medications are cost-effective. […] They are not usually started until one to two weeks after an acute flare has resolved, due to theoretical concerns of worsening the attack. […] While it has been recommended that urate-lowering measures should be increased until serum uric acid levels are below 300-360 mol/L (5.0-6.0 mg/dL), there is little evidence to support this practice over simply putting people on a standard dose of allopurinol. […] If these medications are in chronic use at the time of an attack, it is recommended that they be continued. […] While historically it is not recommended to start allopurinol during an acute attack of gout, this practice appears acceptable. […] Allopurinol blocks uric acid production, and is the most commonly used agent.

• #26 Urate-Lowering Therapy for the Prevention and Treatment of Gout Flare

  https://www.uspharmacist.com/article/uratelowering-therapy-for-the-prevention-and-treatment-of-gout-flare

  Gout is one of the most common rheumatologic arthritic diseases in the United States. Preventing future gout attacks requires lowering serum urate levels to promote dissolution of urate crystals, which is accomplished by reducing the production of serum uric acid or promoting its excretion. Xanthene oxidase inhibitors (XOIs), including allopurinol and febuxostat, are first-line agents for the prevention of acute attacks. Probenecid, a uricosuric agent, is an appropriate adjunctive therapy or second-line agent when XOIs are contraindicated or poorly tolerated. […] Management of gout falls into two categories: treatment of acute gout attacks and prophylaxis of gout flares. The goal of treating acute attacks is to resolve arthritic pain and inflammation. […] Prophylactic treatment of gout flare-ups consists of lowering serum urate levels by reducing the production of uric acid or increasing the excretion of urate from the body.

• #27 Gout – Wikipedia

  https://en.wikipedia.org/wiki/Gout

  Long term therapy is safe and well-tolerated and can be used in people with renal impairment or urate stones, although hypersensitivity occurs in a small number of individuals. […] Febuxostat is only recommended in those who cannot tolerate allopurinol. […] Probenecid appears to be less effective than allopurinol and is a second line agent. […] Pegloticase is an option for the 3% of people who are intolerant to other medications. […] Lesinurad reduces blood uric acid levels by preventing uric acid absorption in the kidneys.

• #28 Gout – Wikipedia

  https://en.wikipedia.org/wiki/Gout

  It is not until this point that medications are cost-effective. […] They are not usually started until one to two weeks after an acute flare has resolved, due to theoretical concerns of worsening the attack. […] While it has been recommended that urate-lowering measures should be increased until serum uric acid levels are below 300-360 mol/L (5.0-6.0 mg/dL), there is little evidence to support this practice over simply putting people on a standard dose of allopurinol. […] If these medications are in chronic use at the time of an attack, it is recommended that they be continued. […] While historically it is not recommended to start allopurinol during an acute attack of gout, this practice appears acceptable. […] Allopurinol blocks uric acid production, and is the most commonly used agent.

• #29 Gout – Wikipedia

  https://en.wikipedia.org/wiki/Gout

  Long term therapy is safe and well-tolerated and can be used in people with renal impairment or urate stones, although hypersensitivity occurs in a small number of individuals. […] Febuxostat is only recommended in those who cannot tolerate allopurinol. […] Probenecid appears to be less effective than allopurinol and is a second line agent. […] Pegloticase is an option for the 3% of people who are intolerant to other medications. […] Lesinurad reduces blood uric acid levels by preventing uric acid absorption in the kidneys.

• #30 Gout – Wikipedia

  https://en.wikipedia.org/wiki/Gout

  Long term therapy is safe and well-tolerated and can be used in people with renal impairment or urate stones, although hypersensitivity occurs in a small number of individuals. […] Febuxostat is only recommended in those who cannot tolerate allopurinol. […] Probenecid appears to be less effective than allopurinol and is a second line agent. […] Pegloticase is an option for the 3% of people who are intolerant to other medications. […] Lesinurad reduces blood uric acid levels by preventing uric acid absorption in the kidneys.

• #31 Latest guidance on the management of gout | The BMJ

  https://www.bmj.com/content/362/bmj.k2893

  An acute attack of gout is likely to require treatment with a NSAID (with gastroprotection for those at high risk of gastrointestinal complications) or colchicine. […] In general, urate lowering therapy (ULT) is targeted to patients with recurrent attacks, tophi, urate arthropathy, or renal damage and to symptomatic patients with very high serum uric acid levels. Allopurinal is the first line option. […] All patients taking ULT require regular monitoring of renal function and serum uric acid level to ensure that the dose is appropriate. For many people, allopurinol 300mg daily will be insufficient to achieve target serum uric acid reductions. […] Despite limited evidence, patients should be encouraged to manage their weight, increase exercise, and reduce alcohol consumption.

• #32

  https://arthritis.ca/about-arthritis/arthritis-types-(a-z)/types/gout/gout-treatment

  Taking medications that regulate uric acid levels is often a long-term treatment option since starting and stopping these medications can trigger a gout attack. […] Your doctor will likely also prescribe another medication, usually an NSAID or colchicine, to take daily for the first few months to help prevent further gout attacks while your body adjusts to taking a uric acid lowering medication. […] Surgery is rarely required for gout.

• #33 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Serum urate should be lowered to a target of less than 5 to 6 mg per dL (297 to 357 mol per L), depending on the crystal and tophaceous burden. […] Weight gain is a significant risk factor for gout in men, whereas weight loss reduces the risk. […] Intake of high-fructose corn syrup should be restricted because the fructose contributes to increased uric acid production as a byproduct of adenosine triphosphate catabolism. […] Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). […] Pharmacologic options for prevention of chronic gout are outlined in Table 4. […] Although avoidance of loop and thiazide diuretics has been recommended for patients with hypertension and gout because these agents can increase uric acid levels, a systematic review found only small increases in the risk of gouty flares. […] Losartan is the only angiotensin receptor blocker with this property.

• #34 Gout: Symptoms, Treatment & Prevention

  https://my.clevelandclinic.org/health/diseases/4755-gout

  The best way to prevent gout is to limit how often you consume high-purine foods and drinks. Make sure you drink plenty of water to help your kidneys function better and avoid dehydration. […] Getting regular exercise can help reduce stress on your joints and reduce your risk for obesity and other health conditions that make you more likely to develop gout. […] Talk to your healthcare provider about medication and changes in your diet that can help you manage your symptoms and reduce how often you experience attacks in the future. […] Cleveland Clinic experts can diagnose gout so you can begin treatment to relieve pain. We help alleviate symptoms and prevent future gout flares.

• #35 Gout Prevention

  https://www.arthritis-health.com/types/gout/gout-prevention

  People at risk for chronic gout will want to take steps to prevent a painful attack. There are several lifestyle and dietary changes that can reduce the risk of a gout attack and joint degeneration associated with gout. […] A combination of one or more of these strategies can help prevent uric acid build-up that leads to a gout attack. […] Consuming alcohol inhibits the body’s ability to excrete uric acid, increasing the risk of hyperuricemia and a gout attack. […] Increasing water intake will help keep the kidneys healthy and help them flush out uric acid from the body. […] Obtaining and maintaining a healthy weight through diet and exercise helps reduce the risk of gout. […] While more research is needed, some evidence suggests that treating sleep apnea may significantly affect the frequency of gout episodes.

• #36

  https://www.prevention.com/health/a20429686/18-ways-to-treat-gout/

  The risk of gout was 40% lower for men who drank 4 to 5 cups of java a day, and 59% lower for men who drank 6 or more a day than for men who didnt drink coffee. […] Drinking two 12-ounce beers a day increases the risk of gout more than twofold. […] If you have high blood pressure and gout, you have double trouble. […] In a 12-year study of 47,150 men with no history of gout, Massachusetts General Hospital researchers found that men who lost 10 pounds and kept it off reduced their risk of gout by 39%. […] The same study showed that being overweight increases your risk of developing gout. […] If youre a man older than 40 with a family history of gout, aim for 1,000 milligrams of calcium a day. […] Be careful when taking vitamins, says Blaurock-Busch, because too much of certain nutrients can make gout worse.

• #37 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Serum urate should be lowered to a target of less than 5 to 6 mg per dL (297 to 357 mol per L), depending on the crystal and tophaceous burden. […] Weight gain is a significant risk factor for gout in men, whereas weight loss reduces the risk. […] Intake of high-fructose corn syrup should be restricted because the fructose contributes to increased uric acid production as a byproduct of adenosine triphosphate catabolism. […] Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). […] Pharmacologic options for prevention of chronic gout are outlined in Table 4. […] Although avoidance of loop and thiazide diuretics has been recommended for patients with hypertension and gout because these agents can increase uric acid levels, a systematic review found only small increases in the risk of gouty flares. […] Losartan is the only angiotensin receptor blocker with this property.

• #38 Gout Treatment Guidelines | Arthritis Foundation

  https://www.arthritis.org/diseases/more-about/gout-treatment-guidelines

  Treating gout with urate-lowering medications is strongly recommended for patients who have tophi (nodules that form from a mass of uric acid crystals at joints or in soft tissues), radiographic evidence (X-ray or other imaging) of damage due to gout, or two or more gout flares per year. […] Allopurinol is strongly recommended as a first-line urate-lowering medication over all others for all patients. […] Using anti-inflammatory medication, such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone or prednisolone as a preventive measure along with urate-lowering meds is strongly recommended over not using anti-inflammatory meds. […] Using treat-to-target strategy by adjusting urate-lowing meds to reach a target uric acid level of less than 6 mg/dl (milligrams per deciliter) is strongly recommended over using a fixed dose of the medication and no target. […] Limiting consumption of alcohol, purines and high-fructose corn syrup are conditionally recommended. […] Using some weight-loss program is conditionally recommended for gout patients who are overweight or obese.

• #39 Gout Diet Dos and Don’ts | Arthritis Foundation

  https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/gout-diet-dos-and-donts

  Maintaining a balanced diet, low in uric acid, is critical for lowering the risk of a gout attack. […] You know that keeping uric acid levels below 6 mg/dl helps to reduce your chance of having a gout attack. […] Drink at least 8 glasses of nonalcoholic beverages a day plain water is best. And if you’re having a flare, increase your intake to 16 glasses a day. The water helps flush uric acid from your system. […] Studies show that drinking low-fat milk and eating low-fat dairy can reduce your uric acid levels and risk of a gout attack. The proteins found in milk promote excretion of uric acid in the urine. […] Alcoholic beverages can increase the risk of gout attacks. […] Long-term coffee drinkers (4-6 cups per day) have less risk of developing gout than people who don’t enjoy the popular brew.

• #40 Gout Diet Dos and Don’ts | Arthritis Foundation

  https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/gout-diet-dos-and-donts

  Vitamin C decreases uric acid levels and can help prevent gout attacks. […] Organ meats (sweetbreads, liver, tongue) are particularly high in purines, which can increase your uric acid levels and spur a gout attack. […] Fill up on lots of green veggies and other non-meat proteins. They don’t raise uric acid levels and may even protect you from gout attacks. […] Eating tart cherries or drinking tart cherry juice may lower your risk of gout attacks. The red-purple pigments in the fruit called anthocyanins have powerful antioxidant and anti-inflammatory properties and are thought to provide protection.

• #41 Gout Diet Dos and Don’ts | Arthritis Foundation

  https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/gout-diet-dos-and-donts

  Vitamin C decreases uric acid levels and can help prevent gout attacks. […] Organ meats (sweetbreads, liver, tongue) are particularly high in purines, which can increase your uric acid levels and spur a gout attack. […] Fill up on lots of green veggies and other non-meat proteins. They don’t raise uric acid levels and may even protect you from gout attacks. […] Eating tart cherries or drinking tart cherry juice may lower your risk of gout attacks. The red-purple pigments in the fruit called anthocyanins have powerful antioxidant and anti-inflammatory properties and are thought to provide protection.

• #42 Gout Diet Dos and Don’ts | Arthritis Foundation

  https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/gout-diet-dos-and-donts

  Maintaining a balanced diet, low in uric acid, is critical for lowering the risk of a gout attack. […] You know that keeping uric acid levels below 6 mg/dl helps to reduce your chance of having a gout attack. […] Drink at least 8 glasses of nonalcoholic beverages a day plain water is best. And if you’re having a flare, increase your intake to 16 glasses a day. The water helps flush uric acid from your system. […] Studies show that drinking low-fat milk and eating low-fat dairy can reduce your uric acid levels and risk of a gout attack. The proteins found in milk promote excretion of uric acid in the urine. […] Alcoholic beverages can increase the risk of gout attacks. […] Long-term coffee drinkers (4-6 cups per day) have less risk of developing gout than people who don’t enjoy the popular brew.

• #43

  https://www.prevention.com/health/a20429686/18-ways-to-treat-gout/

  The risk of gout was 40% lower for men who drank 4 to 5 cups of java a day, and 59% lower for men who drank 6 or more a day than for men who didnt drink coffee. […] Drinking two 12-ounce beers a day increases the risk of gout more than twofold. […] If you have high blood pressure and gout, you have double trouble. […] In a 12-year study of 47,150 men with no history of gout, Massachusetts General Hospital researchers found that men who lost 10 pounds and kept it off reduced their risk of gout by 39%. […] The same study showed that being overweight increases your risk of developing gout. […] If youre a man older than 40 with a family history of gout, aim for 1,000 milligrams of calcium a day. […] Be careful when taking vitamins, says Blaurock-Busch, because too much of certain nutrients can make gout worse.

• #44 Gout and kidney disease: Symptoms, causes & prevention | American Kidney Fund

  https://www.kidneyfund.org/living-kidney-disease/health-problems-caused-kidney-disease/gout/gout-prevention

  Gout is a form of arthritis caused by crystals that form in the joins from too much uric acid in your blood. Kidney disease can increase your risk for gout, and having gout may affect your kidneys. […] If you have gout, talk to your doctor about preventing kidney disease. […] One in 10 people with chronic kidney disease (CKD) have gout, and about 1 in 4 people with gout have CKD. […] As the urate crystals pass through your kidneys, they can cause damage and scarring, leading to kidney damage, kidney disease, and kidney failure over time, especially if your gout is left untreated. […] While there is no cure for gout, there are things you can do to reduce swelling and manage pain. […] Gout is usually treated with medicine, but there are some lifestyle changes you can make to help prevent and decrease the number of gout attacks you experience. […] There is evidence that vitamin C can lower uric acid levels and help manage gout. […] Avoiding foods high in purines can help manage gout.

• #45 Gout Diet Dos and Don’ts | Arthritis Foundation

  https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/gout-diet-dos-and-donts

  Vitamin C decreases uric acid levels and can help prevent gout attacks. […] Organ meats (sweetbreads, liver, tongue) are particularly high in purines, which can increase your uric acid levels and spur a gout attack. […] Fill up on lots of green veggies and other non-meat proteins. They don’t raise uric acid levels and may even protect you from gout attacks. […] Eating tart cherries or drinking tart cherry juice may lower your risk of gout attacks. The red-purple pigments in the fruit called anthocyanins have powerful antioxidant and anti-inflammatory properties and are thought to provide protection.

• #46 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Serum urate should be lowered to a target of less than 5 to 6 mg per dL (297 to 357 mol per L), depending on the crystal and tophaceous burden. […] Weight gain is a significant risk factor for gout in men, whereas weight loss reduces the risk. […] Intake of high-fructose corn syrup should be restricted because the fructose contributes to increased uric acid production as a byproduct of adenosine triphosphate catabolism. […] Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). […] Pharmacologic options for prevention of chronic gout are outlined in Table 4. […] Although avoidance of loop and thiazide diuretics has been recommended for patients with hypertension and gout because these agents can increase uric acid levels, a systematic review found only small increases in the risk of gouty flares. […] Losartan is the only angiotensin receptor blocker with this property.

• #47

  https://www.prevention.com/health/a20429686/18-ways-to-treat-gout/

  The risk of gout was 40% lower for men who drank 4 to 5 cups of java a day, and 59% lower for men who drank 6 or more a day than for men who didnt drink coffee. […] Drinking two 12-ounce beers a day increases the risk of gout more than twofold. […] If you have high blood pressure and gout, you have double trouble. […] In a 12-year study of 47,150 men with no history of gout, Massachusetts General Hospital researchers found that men who lost 10 pounds and kept it off reduced their risk of gout by 39%. […] The same study showed that being overweight increases your risk of developing gout. […] If youre a man older than 40 with a family history of gout, aim for 1,000 milligrams of calcium a day. […] Be careful when taking vitamins, says Blaurock-Busch, because too much of certain nutrients can make gout worse.

• #48 Gout: Symptoms, Treatment & Prevention

  https://my.clevelandclinic.org/health/diseases/4755-gout

  The best way to prevent gout is to limit how often you consume high-purine foods and drinks. Make sure you drink plenty of water to help your kidneys function better and avoid dehydration. […] Getting regular exercise can help reduce stress on your joints and reduce your risk for obesity and other health conditions that make you more likely to develop gout. […] Talk to your healthcare provider about medication and changes in your diet that can help you manage your symptoms and reduce how often you experience attacks in the future. […] Cleveland Clinic experts can diagnose gout so you can begin treatment to relieve pain. We help alleviate symptoms and prevent future gout flares.

• #49 Gout – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/gout/diagnosis-treatment/drc-20372903

  Medications that improve uric acid removal. Drugs such as probenecid (Probalan) help improve your kidneys’ ability to remove uric acid from your body. […] Medications are often the most effective way to treat gout attacks and prevent recurrent symptom flares. However, lifestyle choices also are important, and you may want to: […] Choose healthier beverages. Limit alcoholic beverages and drinks sweetened with fruit sugar (fructose). Instead, drink plenty of nonalcoholic beverages, especially water. […] Avoid foods high in purines. Red meat and organ meats, such as liver, are especially high in purines. […] Exercise regularly and lose weight. Keeping your body at a healthy weight reduces your risk of gout. Choose low-impact activities such as walking, bicycling and swimming which are easier on your joints.

• #50 Gout Prevention

  https://www.arthritis-health.com/types/gout/gout-prevention

  People at risk for chronic gout will want to take steps to prevent a painful attack. There are several lifestyle and dietary changes that can reduce the risk of a gout attack and joint degeneration associated with gout. […] A combination of one or more of these strategies can help prevent uric acid build-up that leads to a gout attack. […] Consuming alcohol inhibits the body’s ability to excrete uric acid, increasing the risk of hyperuricemia and a gout attack. […] Increasing water intake will help keep the kidneys healthy and help them flush out uric acid from the body. […] Obtaining and maintaining a healthy weight through diet and exercise helps reduce the risk of gout. […] While more research is needed, some evidence suggests that treating sleep apnea may significantly affect the frequency of gout episodes.

• #51 Gout Diet Dos and Don’ts | Arthritis Foundation

  https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/gout-diet-dos-and-donts

  Maintaining a balanced diet, low in uric acid, is critical for lowering the risk of a gout attack. […] You know that keeping uric acid levels below 6 mg/dl helps to reduce your chance of having a gout attack. […] Drink at least 8 glasses of nonalcoholic beverages a day plain water is best. And if you’re having a flare, increase your intake to 16 glasses a day. The water helps flush uric acid from your system. […] Studies show that drinking low-fat milk and eating low-fat dairy can reduce your uric acid levels and risk of a gout attack. The proteins found in milk promote excretion of uric acid in the urine. […] Alcoholic beverages can increase the risk of gout attacks. […] Long-term coffee drinkers (4-6 cups per day) have less risk of developing gout than people who don’t enjoy the popular brew.

• #52 Gout remedies: 10 natural treatments and home remedies

  https://www.medicalnewstoday.com/articles/324972

  There is no cure for gout. However, a combination of medications, home remedies, and self-care strategies, such as staying hydrated and applying ice, may help to keep gout in remission. […] Making dietary changes can help people reduce their purine levels and the likelihood of having a gout flare. […] Drinking enough water encourages the kidneys to release excess fluid and flush uric acid out of the body, reducing gout symptoms. […] During a gout flare-up, they recommend drinking up to 16 cups of water. […] Water is best to stay hydrated. However, other clear fluids, such as clear broths and herbal teas, are also good choices. People should avoid alcohol and sodas, which are high in purines. […] Stress can worsen gout symptoms. […] One way to reduce swelling is by elevating the affected joints. This encourages blood and fluid to move away from the joint and back toward the heart.

• #53 How to Prevent Gout

  https://www.verywellhealth.com/how-to-prevent-gout-5112846

  People genetically predisposed to gout can still prevent gout attacks from occurring by making certain lifestyle changes. […] For people with only mildly elevated uric acid levels, dietary changes may be all that’s needed to prevent gout. […] Avoiding and limiting foods that are high in purines can greatly reduce the risk of gout. […] Research has shown that eating nutritionally well-designed food, such as vegetables and dairy products, causes urine alkalinization, which promotes uric acid excretion. […] Alcohol is high in purines, which is why it contributes to gout. […] Losing weight can potentially reduce the risk of gout because it reduces a person’s average serum uric acid levels. […] For some people, stress can trigger gout attacks. […] Water plays a vital role in preventing gout attacks because it helps flush uric acid from the body and prevent a buildup of crystals. […] Certain drugs can help prevent a gout flare-up. […] People with genetic predispositions for gout cannot avoid the condition entirely, but gout attacks can be greatly reduced by making dietary and lifestyle changes.

• #54 Gout Prevention

  https://www.arthritis-health.com/types/gout/gout-prevention

  People at risk for chronic gout will want to take steps to prevent a painful attack. There are several lifestyle and dietary changes that can reduce the risk of a gout attack and joint degeneration associated with gout. […] A combination of one or more of these strategies can help prevent uric acid build-up that leads to a gout attack. […] Consuming alcohol inhibits the body’s ability to excrete uric acid, increasing the risk of hyperuricemia and a gout attack. […] Increasing water intake will help keep the kidneys healthy and help them flush out uric acid from the body. […] Obtaining and maintaining a healthy weight through diet and exercise helps reduce the risk of gout. […] While more research is needed, some evidence suggests that treating sleep apnea may significantly affect the frequency of gout episodes.

• #55 Gout – Wikipedia

  https://en.wikipedia.org/wiki/Gout

  Risk of gout attacks can be lowered by complete abstinence from drinking alcoholic beverages, reducing the intake of fructose (e.g. high fructose corn syrup), sucrose, and purine-rich foods of animal origin, such as organ meats and seafood. […] Eating dairy products, vitamin C-rich foods, coffee, and cherries may help prevent gout attacks, as does losing weight. […] Gout may be secondary to sleep apnea via the release of purines from oxygen-starved cells. Treatment of apnea can lessen the occurrence of attacks. […] As of 2020, allopurinol is generally the recommended preventative treatment if medications are used. […] A number of other medications may occasionally be considered to prevent further episodes of gout, including probenecid, febuxostat, benzbromarone, and colchicine. […] Long term medications are not recommended until a person has had two attacks of gout, unless destructive joint changes, tophi, or urate nephropathy exist.

• #56 Diagnosis, Treatment, and Prevention of Gout | AAFP

  https://www.aafp.org/pubs/afp/issues/2014/1215/p831.html

  Serum urate should be lowered to a target of less than 5 to 6 mg per dL (297 to 357 mol per L), depending on the crystal and tophaceous burden. […] Weight gain is a significant risk factor for gout in men, whereas weight loss reduces the risk. […] Intake of high-fructose corn syrup should be restricted because the fructose contributes to increased uric acid production as a byproduct of adenosine triphosphate catabolism. […] Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). […] Pharmacologic options for prevention of chronic gout are outlined in Table 4. […] Although avoidance of loop and thiazide diuretics has been recommended for patients with hypertension and gout because these agents can increase uric acid levels, a systematic review found only small increases in the risk of gouty flares. […] Losartan is the only angiotensin receptor blocker with this property.

• #57

  https://www.prevention.com/health/a20429686/18-ways-to-treat-gout/

  The risk of gout was 40% lower for men who drank 4 to 5 cups of java a day, and 59% lower for men who drank 6 or more a day than for men who didnt drink coffee. […] Drinking two 12-ounce beers a day increases the risk of gout more than twofold. […] If you have high blood pressure and gout, you have double trouble. […] In a 12-year study of 47,150 men with no history of gout, Massachusetts General Hospital researchers found that men who lost 10 pounds and kept it off reduced their risk of gout by 39%. […] The same study showed that being overweight increases your risk of developing gout. […] If youre a man older than 40 with a family history of gout, aim for 1,000 milligrams of calcium a day. […] Be careful when taking vitamins, says Blaurock-Busch, because too much of certain nutrients can make gout worse.

• #58 Gout and kidney disease: Symptoms, causes & prevention | American Kidney Fund

  https://www.kidneyfund.org/living-kidney-disease/health-problems-caused-kidney-disease/gout

  Gout is a form of arthritis caused by crystals that form in the joins from too much uric acid in your blood. Kidney disease can increase your risk for gout, and having gout may affect your kidneys. […] If you have gout, talk to your doctor about preventing kidney disease. […] One in 10 people with chronic kidney disease (CKD) have gout, and about 1 in 4 people with gout have CKD. […] If you have kidney disease, your body may have trouble removing uric acid. This leads to uric acid buildup and crystals, which can cause gout. […] Gout may also damage the kidneys over time if left untreated. […] Gout is usually treated with medicine, but there are some lifestyle changes you can make to help prevent and decrease the number of gout attacks you experience. […] There is evidence that vitamin C can lower uric acid levels and help manage gout. […] It’s also important to stay hydrated if you have gout because water can prevent uric acid from building up. […] Avoiding foods high in purines can help manage gout.

• #59 Management of gout in chronic kidney disease: a G-CAN Consensus Statement on the research priorities | Nature Reviews Rheumatology

  https://www.nature.com/articles/s41584-021-00657-4

  Gout and chronic kidney disease (CKD) frequently coexist, but quality evidence to guide gout management in people with CKD is lacking. […] The use of urate-lowering therapy (ULT) in the context of advanced CKD varies greatly, and professional bodies have issued conflicting recommendations regarding the treatment of gout in people with concomitant CKD. […] This Consensus Statement from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) discusses the evidence and/or lack thereof for the management of gout in people with CKD and identifies key areas for research to address the challenges faced in the management of gout and CKD. […] Care for people with gout and CKD presents important challenges. […] However, quality evidence to guide the management of gout in people with CKD is lacking, owing at least in part to the exclusion of people with CKD from trials of gout therapies, failure to report results stratified by renal function and inconsistencies in the outcome measures used and reported.

• #60 Nutrition and healthy eating

  https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524

  Diet choices can affect gout, a painful form of arthritis. Gout happens when high levels of uric acid cause crystals to form in the blood. The crystals build up in and around a joint. […] Changing your diet isnt a cure for gout. But it may lower the risk of new gout attacks and slow damage to the joints. […] Following a diet designed to manage gout can help limit the amount of uric acid the body makes and can help your body get rid of it. Diet isn’t likely to lower uric acid level in your blood enough to treat your gout without medicine. But it may help lower the number of attacks you have and limit how bad they are. […] Following a gout-focused diet, cutting calories and getting regular exercise also can help you get to and stay at a healthy weight. This can improve your overall health.

• #61 Lifestyle changes to reduce the risk of gout attacks – Harvard Health

  https://www.health.harvard.edu/pain/lifestyle-changes-to-reduce-the-risk-of-gout-attacks

  Lifestyle measures, such as dietary changes, can help lower levels of uric acid, the chemical that causes gout by forming crystals that deposit in joints. However, for most people, changes in diet alone are not enough to prevent gout. To reduce uric acid levels enough to stop attacks, medication is usually needed. Still making changes in what you eat can lead to fewer gouty flares. […] Just losing weight can lower uric acid levels. Drinking plenty of fluids is also helpful. It’s also important to limit sweetened drinks and alcohol, as these can increase uric acid levels. […] But just eliminating purine-rich foods and alcohol is not enough to prevent attacks for most people with gout. Medications are used to treat an acute attack, and you can take other medications over the long term to prevent further attacks. When it comes to diet, focus on an overall healthy eating pattern, drink plenty of fluids, and try to lose excess weight.

• #62 Gout Treatment Guidelines | Arthritis Foundation

  https://www.arthritis.org/diseases/more-about/gout-treatment-guidelines

  Treating gout with urate-lowering medications is strongly recommended for patients who have tophi (nodules that form from a mass of uric acid crystals at joints or in soft tissues), radiographic evidence (X-ray or other imaging) of damage due to gout, or two or more gout flares per year. […] Allopurinol is strongly recommended as a first-line urate-lowering medication over all others for all patients. […] Using anti-inflammatory medication, such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone or prednisolone as a preventive measure along with urate-lowering meds is strongly recommended over not using anti-inflammatory meds. […] Using treat-to-target strategy by adjusting urate-lowing meds to reach a target uric acid level of less than 6 mg/dl (milligrams per deciliter) is strongly recommended over using a fixed dose of the medication and no target. […] Limiting consumption of alcohol, purines and high-fructose corn syrup are conditionally recommended. […] Using some weight-loss program is conditionally recommended for gout patients who are overweight or obese.

• #63 Latest guidance on the management of gout | The BMJ

  https://www.bmj.com/content/362/bmj.k2893

  An acute attack of gout is likely to require treatment with a NSAID (with gastroprotection for those at high risk of gastrointestinal complications) or colchicine. […] In general, urate lowering therapy (ULT) is targeted to patients with recurrent attacks, tophi, urate arthropathy, or renal damage and to symptomatic patients with very high serum uric acid levels. Allopurinal is the first line option. […] All patients taking ULT require regular monitoring of renal function and serum uric acid level to ensure that the dose is appropriate. For many people, allopurinol 300mg daily will be insufficient to achieve target serum uric acid reductions. […] Despite limited evidence, patients should be encouraged to manage their weight, increase exercise, and reduce alcohol consumption.

• #64 Gout Treatment Guidelines | Arthritis Foundation

  https://www.arthritis.org/diseases/more-about/gout-treatment-guidelines

  Treating gout with urate-lowering medications is strongly recommended for patients who have tophi (nodules that form from a mass of uric acid crystals at joints or in soft tissues), radiographic evidence (X-ray or other imaging) of damage due to gout, or two or more gout flares per year. […] Allopurinol is strongly recommended as a first-line urate-lowering medication over all others for all patients. […] Using anti-inflammatory medication, such as colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone or prednisolone as a preventive measure along with urate-lowering meds is strongly recommended over not using anti-inflammatory meds. […] Using treat-to-target strategy by adjusting urate-lowing meds to reach a target uric acid level of less than 6 mg/dl (milligrams per deciliter) is strongly recommended over using a fixed dose of the medication and no target. […] Limiting consumption of alcohol, purines and high-fructose corn syrup are conditionally recommended. […] Using some weight-loss program is conditionally recommended for gout patients who are overweight or obese.

• #65

  https://bpac.org.nz/2021/gout-part1.aspx

  Gout management in New Zealand needs to change because Mori and Pacific peoples in particular are not receiving the medicines according to their level of need. […] Once urate-lowering medicines are started, monitoring is also often sub-optimal, meaning that many patients will still have serum urate concentrations above recommended levels for treating gout. […] Most patients with gout are able to achieve serum urate targets if they are provided with effective support. […] Urate-lowering treatment should be discussed with all patients with gout once a diagnosis has been established. […] Patients with symptomatic hyperuricaemia and any of the following should start urate-lowering treatment: Two or more flares per year, tophi or erosions on X-ray, renal impairment, past urolithiasis, serum urate level 0.54 mmol/L. […] Regular use is the key to long-term management. […] Rongo rkau (traditional plant remedies with healing properties) may be used by some Mori patients to treat flares of gout. Urate-lowering medicines can be used safely in combination with Rongo rkau and should not be discouraged.

• #66 Gout

  https://www.nhs.uk/conditions/gout/

  Gout can come back every few months or it may be years. It can come back more often if it’s not treated. […] If you have frequent attacks or high levels of uric acid in your blood, you may need to take uric acid-lowering medicine. […] It’s important to take uric acid-lowering medicine regularly, even when you no longer have symptoms. […] Making healthy lifestyle choices may mean you can stop or reduce further gout attacks: […] try to lose weight if you are overweight, but avoid crash diets […] eat a healthy diet your doctor may give you a list of foods to include or limit […] have some alcohol-free days each week try not to drink more than 14 units of alcohol a week […] drink plenty of fluids to avoid getting dehydrated […] exercise regularly but avoid intense exercise or putting lots of pressure on joints […] try to quit smoking […] ask a GP about vitamin C supplements. […] do not have lots of sugary drinks and snacks.

• #67 Gout and kidney disease: Symptoms, causes & prevention | American Kidney Fund

  https://www.kidneyfund.org/living-kidney-disease/health-problems-caused-kidney-disease/gout/gout-prevention

  Gout is a form of arthritis caused by crystals that form in the joins from too much uric acid in your blood. Kidney disease can increase your risk for gout, and having gout may affect your kidneys. […] If you have gout, talk to your doctor about preventing kidney disease. […] One in 10 people with chronic kidney disease (CKD) have gout, and about 1 in 4 people with gout have CKD. […] As the urate crystals pass through your kidneys, they can cause damage and scarring, leading to kidney damage, kidney disease, and kidney failure over time, especially if your gout is left untreated. […] While there is no cure for gout, there are things you can do to reduce swelling and manage pain. […] Gout is usually treated with medicine, but there are some lifestyle changes you can make to help prevent and decrease the number of gout attacks you experience. […] There is evidence that vitamin C can lower uric acid levels and help manage gout. […] Avoiding foods high in purines can help manage gout.

• #68 Efficacy and safety of gout flare prophylaxis and therapy use in people with chronic kidney disease: a Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)-initiated literature review | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-021-02416-y

  Gout flare prophylaxis and therapy use in people with underlying chronic kidney disease (CKD) is challenging, given limited treatment options and risk of worsening renal function with inappropriate treatment dosing. This literature review aimed to describe the current literature on the efficacy and safety of gout flare prophylaxis and therapy use in people with CKD stages 3-5. Information on the efficacy and safety outcomes of gout flare prophylaxis and therapy use stratified by renal function is lacking. Clinical trial results cannot be extrapolated for those with advanced CKD. Where possible, current and future gout flare studies should include patients with CKD and with study outcomes reported based on renal function and using standardised gout flare definition. Gout flares, when inadequately treated, can have a profound impact on physical functioning and quality of life. According to the 2020 American College of Rheumatology (ACR) guideline, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), and parenteral/oral glucocorticoids are recommended as the preferred first-line treatment options for managing gout flares. These anti-inflammatory treatment options are also recommended as short-term prophylaxis for when commencing urate-lowering therapy (ULT). However, the use of gout flare prophylaxis and therapy in people with CKD is not always straightforward. In the context of minimal or absence of residual renal function, treatment options for gout flare are limited, with potential risks of further renal impairment. Renally adjusted dosing is often required in people with CKD, although there is no specific evidence-based guidance in monitoring the efficacy and safety of the treatment used. Overall, for all anti-inflammatory drugs used for gout flare, lack of consensus on the appropriate dosing and treatment monitoring for this high-risk comorbid population remains. The extent of this deficiency in the literature in terms of the efficacy and safety data for gout flare prophylaxis and therapy is unknown. This review explores the current literature on the efficacy and safety outcome data on the use of gout flare prophylaxis and therapy in people with CKD stage 3. Without limiting the publication date and study design, we were able to capture all of the efficacy and/or safety data for different anti-inflammatory therapy used for gout flare in people with underlying renal impairment. Overarchingly, this review has highlighted the absence of conclusive data on efficacy or safety in gout flare prophylaxis and therapy use in patients with underlying advanced CKD. Current and future gout flare studies should include patients with CKD and inform study results stratified by renal function as well as using standardised gout flare definitions in the study design.

• #69 Guidelines for the treatment of gout: a Swiss perspective

  https://smw.ch/index.php/smw/article/download/2218/3316?inline=1

  Gout is a common condition and its management is suboptimal. The treatment of gout rests on two primary objectives the relief of pain of the acute gouty attack and the reduction of serum urate to a level that prevents further urate crystal deposition. Dietary modifications and avoidance of drugs that provoke hyperuricaemia are indispensable adjuncts to pharmacological therapy in patients with established gout, but are generally insufficient by themselves. All guidelines recommend initiating ULT in cases of established gout (i.e. presence of tophi or evidence of multiple joint involvement and recurrent attacks, joint damage with typical erosions). There is no consensus on whether pharmacotherapy should be started after the first attack of gout in all patients, but if a patient has had more than two attacks, it is usually recommended. All the guidelines, the Japanese guideline being the exception, currently do not recommend treatment of asymptomatic hyperuricaemia. Acute flares are frequently precipitated by the introduction of ULT. The flare rate is highest during the first 3 months of starting ULT, but the increase can persist for up to 6 months, hence the recommendation to give prophylaxis against gout flares for up to 6 months. Colchicine is probably the drug most frequently recommended for prophylaxis, on the basis of data from numerous randomised controlled trials of ULT. The daily dose is 0.5 to 1 mg daily and the dose should be adjusted in the presence of renal impairment. Recent randomised controlled trials of ULTs have included colchicine as prophylaxis on starting therapy. A significant flare rate was observed when prophylaxis was only given for 2 months, hence the recommendation for a 6-month duration of prophylaxis. In patients with non-tophaceous gout, the ACR guidelines have also recommended prophylaxis to be maintained for 3 months after the patient has achieved his target urate level. Reducing the serum urate level in order to prevent crystal deposition and accumulation is the cornerstone of our therapeutic approach in gout. The aim of ULT is to bring the urate level to less than 360 mol/l (6 mg/dl), which is generally accepted to be the solubility threshold of urate in blood. All guidelines recognise that this is the minimum target we should aim for in our patients, and in some clinical situations, such as tophaceous gout, the target should be even lower (e.g., below 300 mol/l). The first step in the management of all cases of gout is to ensure that the patient is informed of nonpharmacological approaches (diet and lifestyle recommendations), the avoidance of substances (including drugs) that elevate serum urate and the importance of long-term adherence to treatment of the condition. The ACR guidelines on the use of allopurinol in patients with CKD differ from the information given in the manufacturers prescribing information and the dose adjustment proposed by Hande. The ACR guidelines recommend starting allopurinol at a dose of 50 mg/day in stage 4 CKD; the dosage can be raised gradually (by 50-mg increments) to doses that may exceed 300 mg/day, but it is important that this is accompanied by patient education and regular monitoring. The use of benzbromarone in CKD has been investigated in only a limited number of studies. For patients on haemodialysis, recommendations are sparse. With allopurinol, prescription of 100 mg on alternate days, given after dialysis, has been suggested. The need to give prophylaxis during ULT is emphasised, as this will improve adherence to ULT, which is usually life-long.

• #70 Gout and Pseudogout Treatment & Management: Approach Considerations, Treatment of Acute Attacks, Treatment of Chronic Gout

  https://emedicine.medscape.com/article/329958-treatment

  Gout is managed in the following 3 stages: […] Providing prophylaxis to prevent acute flares […] The American College of Rheumatology (ACR) published guidelines on the treatment and prophylaxis of acute gouty arthritis and the management of hyperuricemia. […] The risk of gout flares emphasizes the importance of providing close coverage, patient education, and prophylaxis, especially during the first year of urate-lowering therapy. […] Because allopurinol, febuxostat, and probenecid change serum and tissue uric acid levels, they may precipitate acute attacks of gout. To reduce this undesired effect, colchicine or low-dose NSAID treatment is provided for at least 6 months. […] When used prophylactically, colchicine can reduce such flares by 85%. […] If the patient develops a gout flare after beginning therapy with a uric acid-lowering agent, the agent should not be discontinued, because discontinuance will only cause another flux in the uric acid level, which may prolong and intensify the attack.

• #71 Management of Gout: Update from the American College of Rheumatology | AAFP

  https://www.aafp.org/pubs/afp/issues/2021/0800/p209.html

  During a second gout flare-up in one year, low-dose allopurinol can be started with anti-inflammatory therapy without worsening the flare-up. […] Urate-lowering therapy is recommended for patients with two or more gout flare-ups per year, tophaceous gout, or damage attributable to gout visible on radiography. […] The ACR recommends starting urate-lowering therapy during an acute flare-up instead of waiting until it resolves. […] Titrating medication slowly increases adherence while reducing flare-ups and tophi. […] Urate-lowering therapy may have to be continued for life. […] Weight loss reduces gout flare-ups.

• #72

  https://bpac.org.nz/2021/gout-part1.aspx

  Gout is a serious condition that is often associated with a range of long-term negative health outcomes, e.g. co-morbid cardiovascular disease, renal failure and reduced life expectancy. […] The management of gout is sub-optimal in New Zealand, and changes need to be made both in community awareness and in the delivery of healthcare; after making a diagnosis, the emphasis should be placed on providing information to patients about their condition, addressing any misconceptions or concerns and supporting appropriate medicine use. […] Discuss urate-lowering treatment with all patients with gout at their first presentation, recommend early initiation and encourage regular and consistent use; lifestyle changes alone are insufficient to prevent future gout flares from occurring. […] Reducing serum urate levels in patients with gout not only means that flares are less likely, it may also reduce the risk of adverse renal and cardiovascular outcomes.

• #73 Gout Treatment : Medications and Lifestyle Adjustments to Lower Uric Acid

  https://www.hopkinsarthritis.org/arthritis-info/gout/gout-treatment/

  Patients who have multiple episodes of acute gout attacks per year or who have tophi on exam are candidates for uric acid lowering therapy. […] Use of uric acid lowering agents will reduce the frequency of gout attacks and over time, reduce tophi formation, and diminish the risk of joint destruction. […] All patients should be encouraged to modify their lifestyle including limiting alcohol intake, encouraging weight loss where appropriate and decreasing food rich in purines. […] Avoidance of purine rich foods and alcohol may help lower uric acid levels and prevent significant fluctuations in serum uric acid that may precipitate acute attacks. […] Eating a healthy balanced diet of low-fat proteins, low-fat dairy and vegetables will help maintain a healthy weight which is beneficial for the prevention of gout attacks as well.

• #74 Gout: Nonpharmacologic strategies for prevention and treatment – UpToDate

  https://www.uptodate.com/contents/gout-nonpharmacologic-strategies-for-prevention-and-treatment

  Gout, also known as monosodium urate crystal deposition disease, is a type of crystalline arthropathy that can cause recurrent episodes of inflammatory arthritis. In patients with gout, an excess of urate can cause monosodium urate crystals to precipitate in joints or other tissues where they elicit an inflammatory response. Thus, therapy for patients with chronic gout aims to reduce serum urate concentration to a level where crystals are less likely to form. While pharmacotherapy is required to achieve this for most patients, nonpharmacologic treatment strategies can also play an important adjunctive role in lowering serum urate concentration for people with gout. […] This topic will review the role of nonpharmacologic strategies for the prevention and treatment of gout, including treatment of comorbid conditions, consideration of medications that affect urate balance, optimization of dietary composition, and patient education.

• #75 Gout: Symptoms, Treatment & Prevention

  https://my.clevelandclinic.org/health/diseases/4755-gout

  The best way to prevent gout is to limit how often you consume high-purine foods and drinks. Make sure you drink plenty of water to help your kidneys function better and avoid dehydration. […] Getting regular exercise can help reduce stress on your joints and reduce your risk for obesity and other health conditions that make you more likely to develop gout. […] Talk to your healthcare provider about medication and changes in your diet that can help you manage your symptoms and reduce how often you experience attacks in the future. […] Cleveland Clinic experts can diagnose gout so you can begin treatment to relieve pain. We help alleviate symptoms and prevent future gout flares.

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