Long-Term Management of Gout

Gout is a common disorder with clinical signs and symptoms resulting from inflammatory responses to monosodium urate crystals deposited in tissues from extracellular fluids saturated for urate. Long-term management of gout focuses on nonpharmacologic and pharmacologic means to achieve and maintain serum urate levels in a subsaturating range. Despite a firm understanding of gout pathophysiology, means to achieve certain diagnosis, and a variety of effective therapies, treatment outcomes remain suboptimal. In this review, available nonpharmacologic and pharmacologic therapies for chronic gout are discussed and a framework is provided for successful achievement and maintenance of goal-range serum urate levels.

Key points

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Management of hyperuricemic individuals, whether asymptomatic or with gout, aims primarily at maintaining serum urate concentrations in a subsaturating range (usually <6 mg/dL), thus preventing or reversing the clinical consequences of urate crystal formation and deposition.
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Although nonpharmacologic (lifestyle) adjustments may lessen the risk for incident gout in hyperuricemic individuals and ameliorate the course of patients with established gout, pharmacologic urate-lowering therapy to achieve goal-range serum urate is, in most instances, required.
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Inhibition of xanthine oxidase (XO) activity with allopurinol at doses titrated to achieve goal-range serum urate levels remains the first-line urate-lowering pharmacotherapy in the US; febuxostat, an alternative XO inhibitor, or benzbromarone (where available) are suitable alternative first-line options, especially for patients at high-risk for allopurinol toxicity.
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Nonadherence to long-term medication use and inadequate monitoring/titration of urate-lowering therapies are important factors contributing to the suboptimal outcomes for patients with gout documented in many countries.
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For patients who have progressed to severe gout with impaired physical function or quality of life (because of either refractoriness to or intolerance of oral urate-lowering agents or inadequate previous therapy), the modified recombinant uricase, pegloticase, is a biological therapeutic option warranting consideration.