Conditions

Treatment options for

Gout

Gout is common and often a source of recurrent pain and disability.

Preventive treatments, if used well, can dramatically reduce symptoms for most people.

The available evidence is limited.

It is not known whether those patients with a first attack or with infrequent flares might benefit from long term treatments.

Treatment options:

Treatment of acute flares

NICE recommends offering one of these 3 options to manage an acute flare of gout, taking into account the person’s comorbidities, coprescriptions and preferences.

  • NSAID, or
  • colchicine, or
  • corticosteroid

Evidence is limited, but all three treatments seem to be equivalent at reducing pain and joint swelling. They have slightly different side effect profiles, summarised in the table below.

Corticosteroids appear to have the fewest side effects:

  •  studies are small and unlikely to fully predict the risk of side effects in vulnerable patients

Ice packs may be a helpful adjunct – see button below.

Outcome     Evidence Quality
Placebo* NSAID
Reduction in pain score by ≥50% at 24 hours 27% 73% LOW (1 trial, 30 patients)
Placebo* Colchicine
Reduction in pain score by ≥50% at 2 weeks 17% 42% MODERATE (1 trial, 132 patients)
NSAID# Colchicine
Pain score at 2 weeks 1.02 0.96 HIGH (no clinical difference)
Diarrhoea 14% 31% HIGH
NSAID# Corticosteroid
Patients with clinically significant pain reduction at 2 weeks 53% 49% MODERATE (n/s difference)
Abdominal pain within 2 weeks 13% 7% MODERATE
Vomiting 5.5% 0.4% HIGH

* Neither of the placebo trials were big enough to deliver information on side effect rates

# NSAID trials were not large enough to show risk of severe upper GI side effects (ulcers, bleeds)

Dietary measures

NICE  recommends that patients should follow a “healthy, balanced diet”.

There is no randomised controlled trial evidence testing dietary modification to reduce gout flares1,2.

RCTs testing dietary supplements such as vitamin C, cherry or pomegranate extract, or enriched skimmed milk powder were of LOW quality and did not show any effect.

Observational evidence shows that a high BMI and a range of dietary factors are associated with an increased risk of gout attacks:

  • excessive meat or seafood consumption
  • excessive alcohol (especially beer and spirits)
  • sugar-sweetened soft drinks, fructose-containing foods

VERY LOW quality evidence

This research does not provide a reliable indication of the treatment effect.

There is a very high possibility that the true effect is greater, smaller or absent.

 

References

1)National Institute for Health and Care Excellence. Gout: diagnosis and management 2022 [Internet]. [London]: NICE; 2022. (NICE guideline [NG10151])

2)Moi JHY, Sriranganathan MK, Edwards CJ, Buchbinder R. Lifestyle interventions for chronic gout. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD010039

3)Singh JA, Reddy SG, Kundukulam J. Risk factors for gout and prevention: a systematic review of the literature. Curr Opin Rheumatol 2011 Mar; 23(2): 192-202

When to start urate lowering therapy (ULT) ?

NICE makes 2 recommendations1:

1) Offer ULT to those with

  • multiple or troublesome flares, tophi or chronic gouty arthritis
  • also those with CKD 3-5 or taking diuretic
    • these groups have a higher chance of flares, see the Prognosis section below

Large benefits on symptom reduction are described in the Treating to target section below.

2) Discuss the option of ULT with those who

  • are experiencing a first flare or who have infrequent flares.

For this second group, there is no direct evidence to guide us.

We don’t know at what point the initiation of ULT will protect these patients from long term consequences of gout.

  • Clinical experience shows that long term uncontrolled gout causes joint damage and disability,
  • but the value of ULT for those with a new diagnosis or those with infrequent flares is unknown.

Below is a summary of what is known about this. There is no definitive answer, but this may support your understanding and advice to patients.

Likelihood of further flares

more

A study using a UK GP clinical database followed up >20,000 patients after a first attack of gout2. After just under 4 years, the rates of further gout flares* in those not treated with allopurinol were:

Number of further flares over 4 years None 1 2 3
Percentage of patients 62% 21% 9% 8%

* Gout flares were defined by a coded entry of gout, accompanied by a prescription for acute treatment

Note: this study probably underestimates the number of flares, missing those not coded properly, or those not presenting at all.

A number of risk factors increased the chance of flares, each one by a few percent only:

  • male sex
  • younger age
  • high BMI
  • history of cardiovascular disease, diabetes, hypertension, CKD
  • alcohol use (effect proportional to intake)
  • diuretic use*

*This from the NICE evidence review, added here for simplicity

Gout as a progressive crystal deposition disease

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Gout has been conceptualised as a progressive disease with 4 stages3:

  • No disease – asymptomatic with normal urate
    • Asymptomatic but with hyperuricaemia and crystal deposition
      • Symptomatic with recurrent flares
        • Chronic gouty arthritis and tophi

The presence of crystal depostion in joints at the asymptomatic stage, and early in the symptomatic stage, has led to the suggestion that early initiation of ULT might be beneficial4,5.

However, this is still only a theoretical idea. The following data illustrate what the current state of knowledge is.

Most people with asymptomatic hyperuricaemia do not develop gout

This graph shows how many people remain gout free over 15 years at various levels of hyperuricaemia:

Reproduced with permission from BMJ Publishing

Unit conversion mg/dL to umol/L: 6 = 356, 7=416, 8=475, 9 = 535, 10=594

Source: data combined from 4 prospective health research cohorts, 20186.

How much crystal deposition is there in early disease?

A few ultrasound studies on small numbers of patients with gout of different severities have shown signs of urate deposition in joints.

These are one-off assessments. The implication for those who are asymptomatic or with early disease is not known.

Characteristics of patients in study Ultrasound findings
50 patients. Asymptomatic/no joint disease. Mean urate 482umol/L

Recruited from rheumatology, cardiology and nephrology clinics7.

25% had a DC sign* in an MTP joint
15 patients. Early gout, not on ULT. Mean urate 637umol/L

Mean of 2 gout attacks, 30 months apart. Recruited from rheumatology clinic8.

40% had a DC sign* in MTP joint

27% had intra-articular tophi in MTP joint

53 patients, longstanding gout. Mean urate 657umol/L

Mean of 15 previous gout attacks over 9 years9.

67% had a DC sign* in MTP joint

74% had intra-articular tophi in MTP joint

*DC sign, “double contour” sign. Hyperechoic enhancement of the chondrosynovial interface secondary to the monosodium urate crystal deposition7.

Risk of osteoarthritis

more

Gout and OA share a number of risk factors (most importantly raised BMI) so often occur together.

There is a plausible but not fully proven mechanism whereby urate crystals trigger cartilage degradation10.

There is another plausible mechanism whereby OA precedes gout: damaged cartilage is more likely to trap crystals10.

A 2016 UK GP database study11 found that:

  • Patients with a gout diagnosis are 1.45 times more likely to develop OA within 10 years than those without gout.
  • Patients with an OA diagnosis are 1.27 times more likely to develop gout within 10 years than those without OA.
    • both figures after correcting for variables

Associations with systemic disorders and mortality

more

Gout is associated with cardiovascular disorders, metabolic syndrome, CKD and increased mortality.

However, no causal link has been established – these conditions share many common risk factors3.

Urate lowering therapy has not been shown to reduce adverse outcomes for these conditions or affect mortality12,13.

  • With regard to CKD, 2 small studies on patients with hyperuricaemia and CKD attending renal clinics have shown some slowing of decline in renal function with allopurinol therapy. These are at high risk of bias and this question requires larger long term studies14,15,16.

 

References

more

1)National Institute for Health and Care Excellence. Gout: diagnosis and management 2022 [Internet]. [London]: NICE; 2022. (NICE guideline [NG10151])

2)Rothenbacher D, Primatesta P, Ferreira A et al. Frequency and risk factors of gout flares in a large population-based cohort of incident gout. Rheumatology 2011 May; 50(5):  973–981

3)Dalbeth N, Choi HK, Joosten LAB et al. Gout. Nat Rev Dis Primers 2019; 5: 69

4)The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology 2017; 56(7): e1–e20

5)Mallen C, Davenport M, Hui G et al. Improving management of gout in primary care: a new UK management guideline.

6)Dalbeth N, Phipps-Green A, Frampton C, et al. Relationship between serum urate concentration and clinically evident incident gout: an individual participant data analysis.

7)Pineda C, Amezcua-Guerra LM, Solano C et al. Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study. Arthritis Res Ther 2011; 13: R4

8)Ottaviani S, Allard A, Bardin T et al. An exploratory ultrasound study of early gout. Clin Exp Rheumatol 2011; 29: 816-21

9)Ottaviani S, Richette P, Allard A et al. Ultrasonography in gout: a case-control study. Clin Exp Rheumatol. 2012 Jul-Aug; 30(4): 499-504

10)Ma CA, Leung YY. Exploring the Link between Uric Acid and Osteoarthritis. Front Med 2017; 4: 225

11)Kuo CF, Grainge MJ, Mallen C et al. Comorbidities in patients with gout prior to and following diagnosis: case-control study. Ann Rheum Dis 2016 Jan; 75(1): 210-7

12)Dalbeth N, Gosling A,  Gaffo A, Abhishek A. Gout. The Lancet  2021; 397(10287): 1843-1855

13)Hay CA, Prior JA, Belcher J et al. Mortality in Patients With Gout Treated With Allopurinol: A Systematic Review and Meta-Analysis. Arthritis Care Res 2021, 73: 1049-1054

14)Goicoechea M, García de Vinuesa S, Verdalles U et al. Effect of Allopurinol in Chronic Kidney Disease Progression and Cardiovascular Risk.

15)Siu YP, Leung KT, Tong MK et al. Use of allopurinol in slowing the progression of renal disease through its ability to lower serum uric acid level. Am J Kidney Dis 2006; 47(1): 51-59

16)Roughley M, Sultan AA, Clarson L et al. Risk of chronic kidney disease in patients with gout and the impact of urate lowering therapy: a population-based cohort study. Arthritis Res Ther 2018; 20: 243

Treating to target

Once a decision to take long term urate lowering therapy (ULT)  has been made, NICE recommends employing a “treat-to-target” strategy aiming for serum urate level <360umol/L

  • and to consider <300umol/L for those with ongoing flares despite reaching <360umol/L

Evidence for this comes from a pragmatic trial in UK primary care comparing usual GP care with a structured, nurse-led care plan revolving around a treat to target strategy.

In patients experiencing multiple flares per year:

  • treat-to-target showed impressive improvements in flare rates and presence of tophi after 2 years
  • with few apparent harms
Usual Care
Treat-to-target strategy
ARR -- Absolute Risk Reduction
NNT -- Number Needed to Treat
RRR -- Relative Risk Reduction
Usual Care
24 people have 2 or more flares per year
Treat-to-target strategy
8 people have 2 or more flares per year
ARR 16% Absolute Risk Reduction
NNT 6 Number Needed to Treat
RRR 67% Relative Risk Reduction

If 100 people like this have a treat-to-target strategy, 16 fewer people will have 2 or more flares per year than those with usual care

Usual Care
12 people have 4 or more flares per year
Treat-to-target strategy
1 person has 4 or more flares per year
ARR 11% Absolute Risk Reduction
NNT 9 Number Needed to Treat
RRR 91% Relative Risk Reduction

If 100 people like this have a treat-to-target strategy, 11 fewer people will have 4 or more flares per year than those with usual care

Usual Care
30 people achieve urate <360umol/L
Treat-to-target strategy
95 people achieve urate <360umol/L
ARR - Absolute Risk Reduction
NNT 1.5 Number Needed to Treat
RRR - Relative Risk Reduction

If 100 people like this have a treat-to-target strategy, 95 will achieve this target urate level compared to 30 of those with usual care

Usual Care
11.3 people have tophi after 2 years
Treat-to-target strategy
2.8 people have tophi after 2 years
ARR 8.4% Absolute Risk Reduction
NNT 12 Number Needed to Treat
RRR 79% Relative Risk Reduction

If 100 people like this have a treat-to-target strategy, 8.4 fewer people will have tophi after 2 years than those with usual care

For the 255 patients assigned to receive treat-to-target care, the following were reported:

  • 12 stopped ULT due to side-effects:
    • 4 x rash or pruritis
    • 4 x reduced eGFR
    • 2 x GI upset
    • 2 x arthralgia
    • all resolved on stopping therapy

Data on harms was not collected for the usual care group.

 

Reference

1)Doherty M, Jenkins W, Richardson H et al. Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. Lancet 2018; 392(10156): 1403-1412

Allopurinol or febuxostat?

Allopurinol is likely to remain the mainstay of gout prophylaxis.

The NICE evidence review for the 2022 guideline1 and two earlier Cochrane reviews2,3 only found a small number of small, short term trials comparing the two.

  • both drugs reduced serum urate
  • not enough data on flare frequency to quantify their benefit
  • no long term data on tophi, joint damage or risk of OA

The best guide to the effect of these drugs comes from the “Treating to Target” data in the previous section.

NICE recommends either drug as a potential first line treatment, with some points of note in the evidence:

  • allopurinol is the most widely used first line drug and was effective at high doses in the “treat-to-target” study above
  • febuxostat 80-120mg lowers urate more than 300mg allopurinol, but
  • febuxostat has not been compared to higher doses of allopurinol (over 300mg)
  • febuxostat may have a greater increase in flare risk in the short term, for example:
    • 36 flares per 100 people with febuxostat 80mg, v
    • 22 flares per 100 people with allopurinol 300mg within first 3 months of treatment1
      • LOW quality evidence

HARMS

The small, short term trials in this evidence review were not large enough to show any significant harms from either treatment.

See the HARMS data in the “Treating to target” section which details side effects in that study – only 12/255 people stopped meds due to side effects all of which resolved.

 

References

1)National Institute for Health and Care Excellence. Gout: diagnosis and management 2022 [Internet]. [London]: NICE; 2022. (NICE guideline [NG10151])

2)Seth R, Kydd ASR, Buchbinder R et al. Allopurinol for chronic gout. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD006077

3)Tayar JH, Lopez‐Olivo MA, Suarez‐Almazor ME. Febuxostat for treating chronic gout. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD008653

Preventing flares while initiating urate lowering therapy (ULT)

ULT can cause acute flares of gout in the first few months after drug initiation or uptitration.

An option recommended by NICE is to co-prescribe colchicine during drug initiation and uptitration, as prophylaxis against these flares.

  • BNF recommends a dose of 500 micograms twice daily for this indication.
  • NICE does not specify a duration of treatment. In the key trial, colchicine prophylaxis was continued for 3 months after target urate level had been reached.
  • Figure below shows flare reduction when co-prescribing colchicine with allopurinol
    • a similar benefit is seen when co-prescribed with febuxostat

NICE also recommends the option of co-prescribing NSAIDs or corticosteroids as an alternative to colchicine where it is not tolerated, though there is no RCT evidence for their use in this role.

 

No colchicine
Colchicine as extra prophylaxis
ARR -- Absolute Risk Reduction
NNT -- Number Needed to Treat
RRR -- Relative Risk Reduction
No colchicine
77 people have 1 flare over 6 months
Colchicine as extra prophylaxis
33 people have 1 flare over 6 months
ARR 44% Absolute Risk Reduction
NNT 2 Number Needed to Treat
RRR 57% Relative Risk Reduction

If 100 people like this take colchicine for 6 months whilst titrating allopurinol, 45 fewer will experience a gout flare compared to those not taking colchicine

No colchicine
64 people have 2 or more flares over 6 months
Colchicine as extra prophylaxis
14 people have 2 or more flares over 6 months
ARR 49% Absolute Risk Reduction
NNT 2 Number Needed to Treat
RRR 78% Relative Risk Reduction

If 100 people like this take colchicine for 6 months whilst titrating allopurinol, 50 fewer will experience two or more gout flares compared to those not taking colchicine

Colchicine was associated with a raised incidence of GI side effects (mainly diarrhoea) in this study:

  • 8 in 22 people taking colchicine reported diarrhoea, compared to
  • 1 in 21 people taking placebo