Prophylaxis for acute gout flares after initiation of urate-lowering therapy

Abstract

This review summarizes evidence relating to prophylaxis for gout flares after the initiation of urate-lowering therapy (ULT). We searched MEDLINE via PubMed for articles published in English from 1963 to 2013 using MEsH terms covering all aspects of prophylaxis for flares. Dispersion of monosodium urate crystals during the initial phase of deposit dissolution with ULT exposes the patient to an increased rate of acute flares that could contribute to poor treatment adherence. Slow titration of ULT might decrease the risk of flares. 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. If these drugs are contraindicated, not tolerated or ineffective, low-dose corticosteroids (prednisone or prednisolone) might be used. Recently, reports for four trials described the efficacy of canakinumab and rilonacept, two IL-1 inhibitors, for preventing flares during the initiation of allopurinol therapy. 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.

Poorly controlled gout: who is doing poorly?

“…(29) The two first-line options for prophylaxis are low-dose colchicine (0.5 mg daily or twice daily) and low-dose nonsteroidal anti-inflammatory drugs, which can be used for up to six months or until target SUA levels are reached. (30) Finally, there may be a perceived lack of options for uratelowering therapy in patients who have adverse drug reactions to allopurinol. Patients with simple rash due to allopurinol can undergo allopurinol desensitisation using a well-established protocol.…”

Identifying Patient Candidates for IL-1 Inhibition: Lessons From Real-World Cases

“…In randomized, controlled trials, both rilonacept and canakinumab have been shown to prevent flares in patients initiating uratelowering therapy (ULT) [4,5]. However, only canakinumab has consistently shown in phase III trials to be effective treatment for acute flares and to reduce the risk of new flares in patients with difficult-to-treat disease [6].…”

The problems associated with the treatment of chronic hyperuricaemia in Serbia

“…U najvećem broju slučajeva ovaj problem se rešava tako što se na početku terapije primenjuju minimalne doze alopurinola od 100 mg dnevno, a doza se zatim postepeno povećava za dodatnih 100 mg dnevno na svake 2-5 nedelja, sve dok se ne postignu ciljne vrednosti serumskih urata, nakon čega doza postaje fiksna [51]. Pored postepenog uvodjenja alopurinola, prevencija akutnog napada gihta se može ostvariti I primenom kolhicina [52]. Kolhicin je alkaloid koji deluje tako što se vezuje za mikrotubule leukocita, dovodi do njihove depolimerizacije I tako ometa njihovo kretanje ka mestu zapaljenja, ten a taj način ostvaruje svoj antiinflamantorni efekat [4].…”