Gout patients may need higher allopurinol dose

Most patients with gout need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to a gout expert.

Probably more than half of people need more than 300mg “if you are going to get to the target level of (6 mg/dL serum urate or lower). Most people probably closer to 400mg.”

A good target serum urate level is 6mg/dL. “If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks.”

In an attempt to get physicians to use a treat-to-target approach in the management of gout, it was noted that “you can only treat urate successfully if you measure it after you start therapy,” something not all clinicians do. “The correct dose is the dose that drops your urate,” said the professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, “I always start low at 50 mg/dL” and titrate upward.

“There’s no rush in trying to drop the level. It’s a lifelong disease.” When counseling patient about hypersensitivity reactions, advise them to stop the drugs as soon as they notice a rash.

Pegylated uricase is “incredibly effective for lowering serum rate,” as well. When pegylated uricase is “given as an IV infusion, serum rate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer.”

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases the risk of an infusion reaction. In that case, “stop the drug.”

For the management of patients who are having an acute gout attack, that he often chooses anakinra (Kineret) so long as the patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, “any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone.”

Colchicine can work “if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks.”

Narcotics do not work well on inflammatory pain and so are not a good choice for an acute gout attack.

A normal serum urate level does not necessarily rule out a gout attack. “Stick a needle in the joint at some point in time to make sure gout is the diagnosis.”