Recognizing And Treating Lower Extremity Gout

Nicholas Romansky, DPM, FACFAS

   Treatment for an acute gout attack should begin as soon as possible. The choices of agent, appropriate dosage and duration of therapy are dependent on coexisting illnesses, clinical circumstances and the severity of the gout attack. Some measures include: re-evaluating the patient’s medication profile, especially diuretic use; the discontinuation of alcohol ingestion; and altering the diet and overall proper hydration.

   Therapeutic options for the management of acute gout include: nonsteroidal anti-inflammatory drugs (NSAIDs); low-dose colchicine; glucocorticoids; intraarticular or oral steroids; corticotropins; and interleukin-1 (IL-1) inhibitors.5,12,14

   In November 2011, Regeneron Pharmaceuticals announced the FDA accepted for review the company’s supplemental biologic licensing application for rilonacept (Arcalyst). Rilonacept is a subcutaneous injection for the prevention of gout flares in patients during the initial months of therapy. The drug would be used in combination with the standard of care for uric acid lowering therapies. Rilonacept is a biologic/monoclonal antibody and an IL-1 inhibitor.

   Oral colchicines and/or NSAIDs are first-line agents for systemic treatment of acute gout in the absence of contraindications.12,15 There have been no high quality, randomized, placebo-controlled trials for acute gouty arthritis performed to date on the effectiveness of interventions for the treatment of gout and prevention of gout with NSAIDs.

   Commonly used medications include: naproxen 500 mg two to three times daily with food; celecoxib (Celebrex, Pfizer) 200 mg BID; ketorolac 10 mg TID; or indomethacin 50 mg TID for five days. One may use a Medrol dose pak for six days or possibly prednisone 10 mg tapering of 10 mg BID for five days, 10 mg qd for five days and 5 mg for five days. Local application of diclofenac 1% gel (Voltaren, Novartis) or diclofenac 3% (Solaraze, PharmaDerm) are other options. It is generally recommended that NSAID dosages continue for five to seven days after an acute attack but gradually taper off.

   Colchicine is highly effective when patients take it within the first 12 to 36 hours of the attack. It acts as an anti-inflammatory but not an analgesic. This drug has been utilized for decades in acute gout. The FDA removed intravenous colchicine for acute gout from the market in the U.S. in 2008 due to inappropriate use and multiple deaths were reported. High doses of colchicine may potentially lead to side effects, particularly troublesome diarrhea.

   Subsequently, it was reformulated as an oral agent and approved by the FDA in July of 2009 and is now marketed as Colcrys (URL Pharma). Colcrys is currently the only single-agent colchicine with FDA approval. Other FDA-approved colchicine formulations contain probenecid (Benemid).

   Low doses of colchicine (0.6 mg) three times a day may be sufficient for the management of patients with acute gout.12 Specifically, one should give 1.2 mg of colchicine for the treatment of acute gout at the first sign of flare-up. This would be followed by a second dose of 0.6 mg in one hour. The recommended prophylactic use for acute gout is 0.6 mg once or twice daily.5

   Colchicine is a tricyclic alkaloid.15 The mechanism of colchicine involves microtubular polymerization, an important process in neutrophil functioning.

   When the use of NSAIDs or colchicines is contraindicated, not properly tolerated or inappropriate for the patient, then one can give glucocorticoids or corticotropins orally or parenterally for acute gouty inflammation depending on the clinical presentation. For single joint involvement, intraarticular aspiration followed by subsequent injection of a corticosteroid into the joint can be effective. This usually involves the use of a short tapering, oral, low-dose systemic corticosteroid such as prednisone or methylprednisolone, typically p.o. but one can also administer it via IV.

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