In France,
colchicine remains the standard treatment for the acute flare of
gout. The lowest dose currently used decreases digestive toxicity. Doses of
colchicine should be adapted to renal function and age, and possible drug interactions should be considered. Non steroidal anti-inflammatory drugs are an alternative to
colchicine, but their use is frequently limited by comorbidity. When these treatments are contraindicated,
corticosteroid injections can be performed after excluding
septic arthritis. Systemic
corticosteroids could be used in severe polyarticular flares. Anti-IL1 should provide a therapeutic alternative for severe cortico dependant
gout with tophus. To prevent acute flares and reduce tophus volume,
uric acid serum level should be reduced and maintained below 60mg/L (360μmol/L). To achieve this objective, it is often necessary to increase the daily dose of
allopurinol above 300mgs, but the need to adapt the dose to renal function is a frequent cause of therapeutic failure. In the absence of renal stone or
renal colic and hyperuraturia, uricosuric drugs are the second-line treatment.
Probenecid is effective when
creatinine clearance is superior to 50mL/min
Benzbromarone, which was withdrawn due to hepatotoxicity, can be obtained on an individualized patient basis in the case of failure of
allopurinol and
probenecid.
Febuxostat, which was recently approved, is a therapeutic alternative.
Diuretics should be discontinued if possible. Use of
fenofibrate should be discussed in the presence of
dyslipidemia and
losartan in patient with
high blood pressure. Uricolytic drugs (
pegloticase), which are currently being investigated, may be useful for the treatment of serious
gout with tophus, especially in the presence of
renal failure. Education of patient, identification and correction of cardiovascular risk factors should not be forgotten.