Prescription Remedies For Gout
GOUT has historically been called "the disease of kings" due to its association with the eating of rich foods and drinking of fine wine. Luxury has its liabilities. However, in reality the disease is not at all limited to the rich and famous. Though rarely fatal, it is a painful rheumatic condition effecting millions of people around the world. And the numbers are on the rise. A study published in the journal Arthritis & Rheumatism in 2011 suggests the number of cases of gout has more than doubled since 1960, currently afflicting over 8 million adults in the U.S.
As a pharmacist I speak to and interact with gout patients every day. If you have gout, or know someone with gout, this article is for you. Here I will quickly review the disease itself, and then focus on explaining all of the currently available prescription treatments for gout.
What Is Gout?
Simply put, gout is a type of arthritis. The word "gout" actually comes from the Latin "gutta" and the Old French "gote" which both mean "a drop." The thought was that gout was caused by something "dropped" from the blood into the joints. They actually were not far off.
Gout is caused by the build-up of uric acid (a normal by-product of protein metabolism) in the blood, resulting in the formation of uric acid crystals in the tissues of joints - most commonly the large toe - but also affecting fingers, elbows and even the ears. Unlike other forms of arthritis, gout may occur sporadically - flaring up from time to time - and thus require an immediate but temporary treatment to relieve the pain.
People suffering from gout may describe their pain this way: The pain is “unbearable,” “the most painful thing that has ever happened to me,” and "worse than broken bones." The words “excruciating,” “burning” and “boiling” are often used [taken from a Gout Pain website].
Risk Factors for Gout
Symptoms of Gout
1. Age Greater than 45
1. Intense Joint Pain
2. Red/Swollen Joint
3. Lingering discomfort
4. Alcohol Consumption
4. Gradually diminishing pain
5. High Blood Pressure
5. Itchy/Peeling skin afterward
6. Fever (sometimes)
7. Purine Rich Foods (red meats & seafood)
7. Nodules (lumps under the skin)
DIAGNOSIS OF GOUT
So, how exactly does a physician determine that a patient actually has gout? The diagnosis is based on a variety of factors. The diagnosis is not always easy to make, as the symptoms associated with gout may be somewhat vague and similar to other arthritic conditions.
First, they will look for some evidence of uric acid crystals in the fluid of a swollen joint. They will do this by removing some of the joint fluid and examining it for crystals.
Other diagnostic criteria used to confirm a diagnosis of gout include (but are not limited to):
- Elevated blood uric acid levels (normal levels are 2.4-6.0mg/dl for females and 3.4-7.0mg/dl for males)
- Painful swollen large toe
- Joint swelling on one side (but not in both)
- Redness over the joints
- Multiple arthritic attacks
Learn About Gout
The best way to learn about gout, after reading this article, is to pick up a good book on the subject like the one offered below:
TREATMENTS FOR GOUT
Because gout is associated with increased levels of uric acid in the blood (though not everyone with increased uric acid has gout) resulting in pain & inflammation the approach to treating gout with prescription medication has focussed on either:
A) Slowing down the PRODUCTION of uric acid IN the body
B) Increasing the EXCRETION (i.e. removal) of uric acid FROM the body
C) Treating the SYMPTOMS of joint pain and inflammation
Therefore, the prescription medication to treat gout tends to fall in one of these 3 categories.
A. PRESCRIPTIONS TO REDUCE PRODUCTION OF URIC ACID
The following medication slow down uric acid production:
1. ALLOPURINOL: Allopurinol was first developed in hopes that it would help treat certain types of leukemia. These hopes were short-lived, and this use for allopurinol was abandoned. It was, however, later revived when its ability to lower uric acid levels in the blood was understood. Allopurinol is known as a Xanthine-Oxidase (XO) inhibitor. It lowers uric acid levels in the blood by inhibiting an enzyme (XO) involved in the normal production of uric acid in the body. This inhibition results in lower uric acid levels and decreased frequency of gout episodes. Allopurinol is not used to relieve an immediate attack of gout, but rather is taken to prevent subsequent attacks and reduce their frequency.
Illustration: I often illustrate how allopurinol works for patients by comparing "uric acid" to a "house" that your body is trying to build. Allopurinol goes in and steals away the "hammers" of the contractors. With fewer hammers...the work goes forward more slowly.
Dosage & administration: 100mg tablet taken once daily, may increase up to 300mg tablet daily. For more severe cases, doses up to 600mg daily may be taken, but should be divided into several daily doses.
2. ULORIC: Uloric is a newer Xanthine Oxidase (XO) inhibitor manufactured by Takeda Pharmaceuticals which appears to be even more effective at lowering uric acid levels in those for whom allopurinol is not working or is not appropriate. It works, however, in essentially the same way that allopurinol works. It is not available generically and is significantly more expensive.
Dosage & administration: 40mg or 80mg once daily.
B. PRESCRIPTIONS TO INCREASE URIC ACID EXCRETION:
The following prescriptions increase the elimination of uric acid from the body:
WHY THE BIG TOE?
Ever wonder why it is that the Big Toe is so often effected by gout? There are a couple theories. Some believe it may be due to the fact that the joint in the big toe receives more pressure and stress due to walking. Others think that it is because uric acid crystals form more quickly in colder parts of the body, such as the toes. Whatever the reason, nearly 90% of gout sufferers will experience symptoms in their big toe.
1. PROBENECID: Probenecid is an oral medication used to enhance the excretion (elimination) of uric acid from the body. Probenecid works in the kidneys, causing more uric acid to be excreted into the urine and less re-absorbed back into the blood stream.
Illustration: I usually illustrate how Probenecid works by comparing the the kidneys to a slide. Probenecid is like applying wax paper to the slide (ever do that as a kid?). It makes uric acid SLIDE out through the kidneys into the urine more quickly and effectively.
Dosage & administration: The usual dosage is 250mg (1/2 tablet) twice daily for 1 week, followed by 500mg twice daily. In patients with normal kidney function, dosages may be increased to 2000mg daily. Liberal fluid intake is important, as well as raising the pH of the urine by taking sodium bicarbonate or potassium citrate. Probenecid should not be started during an acute attack of gout, but may be continued during an attack if necessary. Probenecid should not be used in patients with kidney impairment.
2. SULFINPYRAZONE: Sulfinpyrazone is another medication historically used to increase the excretion of uric acid, though it is not currently being used. I include the name here merely for reference sake (in case you have an old drug reference book).
3. KRYSTEXXA: Krystexxa is one of the latest approaches to treating otherwise resistant cases of gout - also known as Refractory Chronic Gout (RCG). Krystexxa is an enzyme administered by injection and works by promoting the conversion of uric acid to allantoin - a water soluble and easily excreted substance. Krystexxa is administered by IV in a physicians office or hospital. The whole process takes about 4 hours and must be repeated every 2 weeks.
C. PRESCRIPTIONS TO REDUCE PAIN & INFLAMMATION
The following medications are used to reduce pain and inflammation associated with an acute attack of gout:
1. NSAIDS - such as indomethacin, naproxen or sulindac are often used as first-line approaches to dealing with gout. These medications have a very low risk of side-effects and are typically well tolerated.
2. Steroids - such as prednisone. This will often be given as a short tapering supply of oral tablets to be taken for 6-7 days. Alternatively an injection of steroids may be administered also.
3. Colchicine (Colcrys) - available in 0.6mg tablets and usually taken 2-3 times daily, colchicine is used if NSAIDs or steroids are inappropriate or ineffective.
DIET & LIFESTYLE MODIFICATION
This article is not suggesting that prescriptions alone are the appropriate way to deal with gout. In fact, they are only recommended after appropriate attempts to control symptoms through basic diet and lifestyle modications fail.
- Lifestyle modifications may include weight loss, if obesity is a potentially contributing factor. Better blood-sugar control may also be advised if the patient is diabetic. Engaging in regular exercise is also beneficial at controlling gout flare-ups and symptoms.
- Prescription medications can also contribute to gout. Most notorious for this are the thiazide-type diuretics used to treat hypertension (high blood pressure) like hydrochlorothiazide (hctz). HCTZ is sometimes taken alone, or it may be combined with other medications to reduce blood pressure like ace-inhibitors (e.g. lisinopril, enalapril) or angiotensin blockers (like Diovan, Atacand or Micardis).
- Dietary changes and restrictions are also recommended. See the chart below for foods/drinks that may contribute to gout.
Lifestyle & Diet for Gout Patients
DID YOU KNOW: CHERRIES!
From Medical News Today: "Eating cherries over a two-day period reduced the risk of gout attacks by 35%, according to a new study led by Boston University (BU) in the US that is being published in the journal Arthritis & Rheumatism."
It is not exactly understood why this is the case. Some believe the cherries act almost like ibuprofen, relieving inflammation resulting from the uric acid crystals.
Foods & Drinks which contribute to GOUT
Beef, Pork, Lamb
Tuna, Shrimp, Lobster, Scallops
High Fructos Corn Syrup
- Gout is an arthritic condition associated with elevated uric acid levels in the blood leading to the development of painful crystals forming in the joints.
- Prescription medications used to treat gout aim at either (1) reducing the production of uric acid, (2) increasing the excretion of uric acid or (3) relieving the pain and inflammation associated with gout attacks.
- Medications do not have to be the first approach. Diet and lifestyle modification may be used to effectively treat gout and control symptoms for many patients.
RESOURCES AND REFERENCES:
Resources for Patients:
What You Need to Know about Gout & Uric Acid - a very helpful pamphlet on gout
Tackle Gout - Many useful resources on this site
Gout - A brief but helpful article by the American Academy of Family Physicians
- CDC: Gout Pathology and Treatment: http://www.cdc.gov/arthritis/basics/gout.htm
- “Prevalence of Gout and Hyperuricemia in the US General Population.” Yanyan Zhu, Bhavik J Pandya, Hyon K Choi." Arthritis & Rheumatism; Published Online: July 28, 2011 (DOI: 10.1002/art.30520).
Jason Poquette RPh © All Rights Reserved