GUIDANCE ON HOW TO MANAGE GOUT - Bradford VTS
1. Patients who have not been tried at all or insufficiently tried with Allopurinol:
We suggest the patient starts Allopurinol at 100mg per day. This should be increased by 100mg per month until the uric acid is at the lower end of normal. Many patients will be sufficiently treated with doses between 100 and 300mg/day but some will need doses up to 600-900 mg/day. Patients with renal impairment are more at risk of side-effects. If a minor rash occurs desensitisation can be tried and is often successful. Refer to BNF for side-effects and interactions.
For the first 3-6 months the patient may need to take gout preventing treatment alongside Allopurinol as this can initially cause gout attacks, however starting Allopurinol at a low dose seems to have a much lower risk of triggering gout attacks.
As gout prophylaxis while establishing Allopurinol treatment the patient can be given either
- Colchicine 500mcg bd or
- Regular slow release NSAID (for example Brufen Retard 800mg bd or Diclofenac SR 75mg bd or Celebrex/Etoricoxib) if renal function/co-morbidity permits or
- 120-160mg Depomedrone IM every 8-12 weeks as required
2. If the patient turns out to be more difficult to treat the following drugs can be beneficial in addition to the above as they have uricosuric properties.
If hypertensive
- consider Losartan and/or Amlodipine
If raised cholesterol
- Fenofibrates
3. Further management of gout patients:
Gout is now considered to be part of the metabolic syndrome and needs to be managed as such. Evidence suggests that poorly treated gout is associated with an increased cardiovascular risk. We suggest you check the patient’s
- cholesterol
- glucose
- blood pressure
and manage abnormalities as indicated. The patient should be encouraged to review their lifestyle, i.e.
- normalising weight if obese
- reducing alcohol intake
- increasing exercise
- Stopping smoking is also advised
In refractory gout, especially if all above measures have failed, we would be very happy to see the patient for further assessment and management.
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