Arthritis, Then and Now

Bret S. Stetka, MD; Nathan Wei, AB, MD


March 22, 2013

In This Article

Gout, Now

Modern gout therapies are rooted in the late 1800s. Following his discovery, Garrod first suggested controlling hyperuricemia through a low-purine diet, still a major component of care today and leaving organ meats and certain fish off the table for gout sufferers. Around that time, uricosuric therapy with salicylates was also first used, later replaced by probenecid, sulfinpyrazone, benzbromarone, and the first xanthine oxidase inhibitor, allopurinol.

Joint aspiration is the modern gold standard for identifying gout; however, diagnosis has also undergone a major revolution with the use of diagnostic ultrasonography. Characteristic findings in a patient with other suspicious markers may abrogate the need for far more invasive arthrocentesis. Another advance highlighted at the American College of Rheumatology's recent Annual Meeting is the coexistence of RA and gout; once thought rare, this is much more common than previously believed.[11]

In 2013, gout is now a very treatable disease. And last year, the American College of Rheumatology released their first-ever gout management guidelines.[12,13] Current recommendations include the use of a xanthine oxidase inhibitor, such as allopurinol or febuxostat, in cases of suspected gout, and targeting a serum uric acid level of 6.0 mg/dL or less. Patients should receive prophylactic colchicine during the first few months of treatment to prevent flares. Certain patients who might be given allopurinol should be screened for a propensity for developing allopurinol toxicity. Combinations of xanthine oxidase inhibitors and uricosuric drugs can be used if the desired serum uric acid is not achieved. Patients with renal insufficiency are a high-risk group, and their dosage of xanthine oxidase inhibitor needs to be adjusted accordingly. Pegloticase can be used in patients with refractory gout, particularly if tophi are present.