31st January 2024

Management

The approach to management of patients with gout and pseudogout are initially similar- symptom control and aim to enable return of joint use and independence. However, the management of pseudogout is more restricted- there are no specific agents that can be used to reduce the crystal deposition in pseudogout, whereas multiple agents are currently in use for the management and prevention of gout. 

Conservative

• Rest, ice and elevate
• Avoid trauma
• Lifestyle changes- encourage exercise and healthy diet

As mentioned previously, gout is linked to purine levels. Increased consumption of food and drink with high levels of purine increases the risk of gout flares occurring.  

Alcohol consumption increases the risk of suffering from gout. Beers and lagers have higher levels of purine than spirits, whereas consuming moderate levels of wine does not increase the risk of gout. The consumption of 2 or more sugar-sweetened drinks in a day also increases the incidence of gout. Consuming high quantities of meats, notably beef, pork, lamb, and seafood increases this risk of gout due to the levels of purine consumption. Reducing the consumption of these products can aid in reducing gout attacks. By contrast, consuming vegetables with high purine content has not demonstrated an increased risk of gout. In addition, people who consume high quantities of dairy products have a lower incidence of gout.

Pharmacological

Consider contraindications to proposed pharmacological therapy prior to initiation. In particular, renal function needs to be considered. Other contraindications include intolerance and, therefore, non-compliance, severe side effects such as peptic ulceration and gastrointestinal bleeding, allergic reaction, previous failure with this agent and medication interactions. Drug-drug interactions are numerous depending on what the patient is taking and should be considered individually.

During an acute flare

• Non-steroidal anti-inflammatory (NSAID) agents- to be continued until 1-2 days after cessation of the attack. (NB Aspirin is not indicated in gout. In fact, low-dose aspirin can affect renal excretion of uric acid and increase the risk of a gout flare)
• Consider co-prescribing a proton pump inhibitor with NSAIDs, particularly if there is a risk of gastric ulceration and GI bleed. 
• Prednisolone is considered for those with an acute flare with difficult symptom control and affecting quality of life. Not all patients with a flare of crystal arthropathy require steroids, and this should be considered on an individual basis. Co-morbidities are also important to consider; for example, those with diabetes will likely suffer from labile blood sugar levels. If steroids are needed, a short course of approximately 5 days only should be used; therefore, weaning is usually not needed. The use of steroids is aimed at the inflammatory response- to dampen this and aid the symptoms of an attack.
• Oral colchicine- be aware of the common side effects of these medications. The main common side effects affect the gastrointestinal system. Colchicine is often used in gout management but the evidence for use in pseudogout is variable. Colchicine is increasingly used in prophylaxis of gout with gradual dose increase as tolerated by the patient.
  • Colchicine is an alkaloid used in the symptomatic relief of pain in attacks of gout and to treat the inflammatory symptoms of Familial Mediterranean Fever.
  • Colchicine works by blocking the mitotic activity during metaphase; it binds to tubulin, which, by forming complexes, prevents elongation, thus impairing the inflammatory process.

Prophylaxis

• Xanthine oxidase inhibitors, such as allopurinol or febuxostat, are used for prevention of gout attacks. Initiation should be avoided during an acute flare, but once initiated, can be continued during flares.
• Allopurinol: allopurinol undergoes first-pass metabolism and is converted to its active form Oxypurinol (Alloxanthine), which acts as an inhibitor of xanthine oxidase enzyme. A starting dose of between 50mg-100mg daily is recommended, with gradual dose increase to a maximum of 900mg in daily divided doses with the aim to reach a target serum urate level <6mg/dL. During an acute gout flare, allopurinol should be continued.
• Febuxostat is a non-purine selective xanthine oxidase inhibitor recommended in the lowering of uric acid levels in a dose-dependent manner in those who are not responsive or intolerant of allopurinol. It has been shown to lower serum urate levels to <6mg/ dL better than allopurinol. 
• Uricase agents, e.g. Pegloticase, can be used to reduce urate levels to prevent further acute flares. 

Surgical intervention

Tophi can be surgically excised, but this will not prevent further tophi from appearing. Patients should be counselled on the risks vs. benefits of surgical intervention, particularly as this is not a definitive solution. Risks include infection, structural damage and failure. People with co-morbidities, such as diabetes mellitus, are at greater risk of these complications. 

Patients sometimes request surgery for joint remodelling or replacement, but again, this does not treat the underlying condition and is not a long-term treatment option. 

References 

• MacMullan P, McCarthy G. Treatment and management of pseudogout: insights for the clinician. Therapeutic Advances in Musculoskeletal Disease. 2011 Dec 21;4(2):121–31.
• Lillicrap M. Crystal arthritis: contemporary approaches to diseases of antiquity. Clinical Medicine. 2007 Jan 1;7(1):60–4.
• CKS is only available in the UK [Internet]. NICE. 2018 [cited 2022 Apr 30]. Available from: https://cks.nice.org.uk/topics/gout/prescribing-information/allopurinol/
• Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Alcohol intake and risk of incident gout in men: a prospective study. The Lancet. 2004 Apr;363(9417):1277–81.
• Leung YY, Yao Hui LL, Kraus VB. Colchicine—Update on mechanisms of action and therapeutic uses. Seminars in Arthritis and Rheumatism. 2015 Dec;45(3):341–50.
• Hainer BL, Matheson E, R. Travis Wilkes. Diagnosis, Treatment, and Prevention of Gout. American Family Physician [Internet]. 2014 [cited 2022 May 9];90(12):831–6. Available from: https://www.aafp.org/afp/2014/1215/p831.html
• Qurie A, Pankaj Bansal, Amandeep Goyal, Musa R. Allopurinol [Internet]. Nih.gov. StatPearls Publishing; 2019 [cited 2022 Apr 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499942/
• Gerriets V, Ishwarlal Jialal. Febuxostat [Internet]. Nih.gov. StatPearls Publishing; 2021 [cited 2022 Apr 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544239/
• Neogi T. Gout. New England Journal of Medicine. 2011 Feb 3;364(5):443–52.