Most Patients Need More Allopurinol to Quiet Gout

NEWPORT BEACH, CALIF. – Most gout patients need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to gout expert Dr. Brian Mandell.

Probably more than half of people need more than 300 mg "if you are going to get to the target level of [6 mg/dL serum urate or lower]. Most people probably need closer to 400 mg," he said (Ann. Rheum. Dis. 1998;57:545-9).

A good target serum urate level is 6 mg/dL. "If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

In a bid to get physicians to use a treat-to-target approach in gout management, Dr. Mandell noted that "you can only treat urate successfully if you measure it after you start therapy," something not all clinicians do. "The correct dose is the dose that drops your urate," said Dr. Mandell, professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, "I always start low at 50 mg/dL" and titrate upward, he said.

"There’s no rush in trying to drop the level. It’s a lifelong disease." When counseling patients about hypersensitivity reactions, Dr. Mandell said that he advises them to stop the drug as soon as they notice a rash and then call him.

Pegylated uricase is "incredibly effective for lowering serum urate," as well, he said. When pegylated uricase is "given as an IV infusion, serum urate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer," Dr. Mandell noted.

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases their risk of an infusion reaction. In that case, "stop the drug," he said.

For management of an acute gout attack, Dr. Mandell said he often chooses anakinra (Kineret) so long as patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, "any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone," he advised.

Colchicine can work "if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks," he said.

Narcotics don’t work well on inflammatory pain and so are not a good choice for an acute attack, Dr. Mandell noted.

A normal serum urate level does not necessarily rule out a gout attack. "Stick a needle in the joint at some point in time to make sure gout is the diagnosis," he said.

Dr. Mandell is a consultant for Novartis, Pfizer, Takeda, and other companies.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – Most gout patients need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to gout expert Dr. Brian Mandell.

Probably more than half of people need more than 300 mg "if you are going to get to the target level of [6 mg/dL serum urate or lower]. Most people probably need closer to 400 mg," he said (Ann. Rheum. Dis. 1998;57:545-9).

A good target serum urate level is 6 mg/dL. "If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

In a bid to get physicians to use a treat-to-target approach in gout management, Dr. Mandell noted that "you can only treat urate successfully if you measure it after you start therapy," something not all clinicians do. "The correct dose is the dose that drops your urate," said Dr. Mandell, professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, "I always start low at 50 mg/dL" and titrate upward, he said.

"There’s no rush in trying to drop the level. It’s a lifelong disease." When counseling patients about hypersensitivity reactions, Dr. Mandell said that he advises them to stop the drug as soon as they notice a rash and then call him.

Pegylated uricase is "incredibly effective for lowering serum urate," as well, he said. When pegylated uricase is "given as an IV infusion, serum urate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer," Dr. Mandell noted.

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases their risk of an infusion reaction. In that case, "stop the drug," he said.

For management of an acute gout attack, Dr. Mandell said he often chooses anakinra (Kineret) so long as patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, "any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone," he advised.

Colchicine can work "if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks," he said.

Narcotics don’t work well on inflammatory pain and so are not a good choice for an acute attack, Dr. Mandell noted.

A normal serum urate level does not necessarily rule out a gout attack. "Stick a needle in the joint at some point in time to make sure gout is the diagnosis," he said.

Dr. Mandell is a consultant for Novartis, Pfizer, Takeda, and other companies.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – Most gout patients need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to gout expert Dr. Brian Mandell.

Probably more than half of people need more than 300 mg "if you are going to get to the target level of [6 mg/dL serum urate or lower]. Most people probably need closer to 400 mg," he said (Ann. Rheum. Dis. 1998;57:545-9).

A good target serum urate level is 6 mg/dL. "If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

In a bid to get physicians to use a treat-to-target approach in gout management, Dr. Mandell noted that "you can only treat urate successfully if you measure it after you start therapy," something not all clinicians do. "The correct dose is the dose that drops your urate," said Dr. Mandell, professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, "I always start low at 50 mg/dL" and titrate upward, he said.

"There’s no rush in trying to drop the level. It’s a lifelong disease." When counseling patients about hypersensitivity reactions, Dr. Mandell said that he advises them to stop the drug as soon as they notice a rash and then call him.

Pegylated uricase is "incredibly effective for lowering serum urate," as well, he said. When pegylated uricase is "given as an IV infusion, serum urate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer," Dr. Mandell noted.

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases their risk of an infusion reaction. In that case, "stop the drug," he said.

For management of an acute gout attack, Dr. Mandell said he often chooses anakinra (Kineret) so long as patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, "any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone," he advised.

Colchicine can work "if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks," he said.

Narcotics don’t work well on inflammatory pain and so are not a good choice for an acute attack, Dr. Mandell noted.

A normal serum urate level does not necessarily rule out a gout attack. "Stick a needle in the joint at some point in time to make sure gout is the diagnosis," he said.

Dr. Mandell is a consultant for Novartis, Pfizer, Takeda, and other companies.

SDEF and this news organization are owned by Frontline Medical Communications.