Features November 2019 Issue

Gout Drugs Are Underused

Learn why skipping gout meds could affect the quality of your life.

More than 9 million Americans live with gout, a form of inflammatory arthritis that causes periodic attacks of painful swelling in the big toes and other joints. These attacks happen as a result of high levels of a substance called uric acid.

Uric acid is a waste product of natural processes in the body. It is eliminated through the gastrointestinal tract and kidneys. If not enough uric acid is removed, it can accumulate in the blood. Once levels exceed 6.8 milligrams per deciliter (mg/dL), uric acid can leave the bloodstream and settle in joints, tendons and under the skin.

Uric acid in joints can form needle-shaped crystals that from time to time can cause the swelling, redness and pain of a gout attack.

Two-Pronged Approach

Gout treatment takes a two-pronged approach. Individual gout attacks are usually treated with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine or corticosteroids to bring down swelling and ease pain.

To prevent future attacks, you need a drug that will reduce uric acid levels. These are called urate-lowering drugs, and the most commonly used one is allopurinol (Aloprim®, Zyloprim®). Another option is febuxostat (Uloric®). Because of a slightly increased risk for death from heart disease, it is used only when allopurinol cannot be used.

Treatment

gouttoe

© ttsz | Getty Images

Uric acid deposits in joints and tendons can dissolve if urate-lowering drugs are taken.

Allopurinol is inexpensive and very effective. Yet, it appears to be underutilized. "Too few people are started on the medication," says Cleveland Clinic rheumatologist Brian Mandell, MD, PhD. "And when people are started on therapy, many are not monitored for the lowering of the uric acid and treated to the effective target level."

A study published in Arthritis & Rheumatology (June 2019) that analyzed data on 5,467 people found that fewer than 38% of those with gout achieved the target uric acid level of less than 6 mg/dl.

Another study, published in Arthritis Research & Therapy (May 2019), found similar lackluster rates of urate-lowering therapy. Only 37% of people with gout took allopurinol, and only half of those with frequent flares regularly used this drug.

Even among people who do start on a drug, many stop taking it. "People with gout may not realize that this is a chronic disease, and we can cure it," says Dr. Mandell.

Stay on Treatment

To effectively treat gout, you have to take urate-lowering therapy consistently. "If you are having frequent flares and you want to treat the disease, you need to dissolve those deposits," says Dr. Mandell.

"If you've already had an attack of gout, you are more likely to have others," says Dr. Mandell. Over time, gout attacks can become more frequent, last longer and involve multiple joints. Eventually, you can have joint damage.

Your doctor should take blood tests to check that your uric acid levels remain at the target. "People with gout should know their uric acid level," says Dr. Mandell.

In the past, doctors advised their patients with gout to avoid foods high in purines, which the body metabolizes into uric acid. Steak, shellfish and seafood were all off-limits. However, research hasn't shown any dramatic benefit of adopting that kind of restrictive diet.

"The idea that you're going to stop eating red meat and your uric acid level is going to plummet to the point where the crystals dissolve is very unlikely," says Dr. Mandell. A heart-healthy diet is never a bad idea, but to ultimately stop future attacks you need to stick with medication.

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