Transcript Practical Diagnosis of Gout - Scioto County Medical Society

Caveat on urate levels
• Serum uric acid level may be normal at the
time of an acute attack.
• Normal level does not rule out gout.
• May be better to recheck the level after 2
weeks
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Resolve the acute flare rapidly
• NSAIDs
• Corticosteroids
• Colchicine
Remember that above may all be limited by
comorbidities !!
Antiinflammatories do not treat the underlying disease.
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Long term approach
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Allopurinol
• Purine “backbone” xanthine oxidase inhibitor
• FDA approved in 1966, most widely used uratelowering drug for the last four decades.
• Basis for the 1988 Nobel Prize in Physiology and
Medicine.
• Starting dose of 50-100mg daily and slowly titrate;
consider prophylaxis against flare.
• Some studies suggested that only 21% of patients on
300mg achieved urate level < 6.0.
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New and Emerging Gout Meds
• febuxostat– oral nonpurine xanthine oxidase
inhibitor FDA approved in 2009 for gout and
hyperuricemia
• pegloticase – PEGylated uricase; not yet FDA
approved-- for advanced tophaceous gout,
administered intravenously.
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Febuxostat
• FDA approved doses are 40mg and 80mg.
• Published RCT looked at higher doses as well.
• Compared to allopurinol, was as good or superior in
achieving goal of sUA <6.0.
• Significant reduction in gout flares and tophi when
sUA goal is maintained.
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A
Allopurinol has a purine backbone.
Febuxostat is a non-purine xanthine oxidase inhibitor.
Febuxostat
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Febuxostat
• Primarily excreted by the liver, only 3% by the kidney; no
dosage reduction required for renal impairment.
• Mild transaminase elevations observed, similar to that of
allopurinol.
• Contraindicated with use of 6-MP, azathioprine, theophylline
• In RCT a higher rate of CV and thromboembolic events noted
(0.14 / 100 pt-years > allopurinol), but a causal relationship
not identified
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Febuxostat
• Primarily excreted by the liver, only 3% by the kidney; no
dosage reduction required for renal impairment.
• Mild transaminase elevations observed, similar to that of
allopurinol.
• Contraindicated with use of 6-MP, azathioprine, theophylline
• In RCT a higher rate of CV and thromboembolic events noted
(0.14 / 100 pt-years > allopurinol), but a causal relationship
not identified
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Febuxostat
• In general 40mg (starting dose) not inferior to 300mg
allopurinol. 80 mg dose produced higher rate of
achieving target sUA level of <6.0 and reduction of
flares
• 5-year findings (FOCUS) showed sustained effect
with maintenance of sUA < 6.0 and nearly complete
suppression of flares
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References (febuxostat)
• Becker, M.A., et al. NEJM.353:2450, December 8,
2005 {“FACT trial”}
• Schumacher, H.R., et al. Rheum. 48; (2),188- 194.
{“FOCUS” 5-year findings}
• Becker, M.A, et al. Arthr & Rheum, 52; (3), 916-923.
• Schumacher, H.R., et al. A&R (Arthr Care &
Research). 59; (11), 1540-1548.
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Thank you !!
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