Febuxostat, which received FDA approval in 2009, was the first oral urate-lowering treatment to be approved since the 1960s. Like allopurinol, this nonpurine xanthine oxidase inhibitor blocks uric acid synthesis.48,49 In a trial reported by Becker et al,50 67% of patients who took febuxostat 80 mg/d reached the target serum urate level (ie, < 6.0 mg/dL), compared with 45% of those who took 40 mg/d of febuxostat and 42% of those taking 300 mg/d of allopurinol. While incidence of adverse events was low in all treatment groups, Hu and Tomlinson51 report that febuxostat is tolerable in patients who are hypersensitive to allopurinol. As with other urate-lowering medications, gout flares are common during the early period of febuxostat use.51
For patients with gout that does not respond to conventional urate-lowering therapy, new options are being introduced. Two agents, each a recombinant form of the enzyme urate oxidase, are designed to convert uric acid into allantoin, which can then be excreted in the urine. Late in 2010, one of these agents, pegloticase, was approved for use in patients with refractory gout.48 In one clinical trial, tophi were reported dissolved in 40% of patients who took pegloticase, but 58% of patients did not achieve the targeted response (ie, serum urate < 6.0 mg/dL), and 77% of patients experienced gout flares.52 Infusion reactions occurred in 26% to 31% of patients, and Reinders and Jansen52 recommended the clinical evaluation of glucocorticoids and other anti-inflammatory agents to prevent the formation of antibodies involved in these reactions.
The second agent, rasburicase, has been approved for treatment and prevention of acute hyperuricemia in adult cancer patients. Rasburicase is now being investigated for use in patients with nonresponsive tophaceous gout.53-55 It can be administered in the form of monthly infusions.54
Patient Education
Educating the patient about modifiable risk factors, such as diet, alcohol consumption, and adherence to the medication regimen, should be a priority.
Patients should be encouraged to target and maintain an ideal body weight, through diet and moderate physical exercise, as a strategy to normalize serum urate levels.27,47 However, they should be advised to avoid “crash dieting,” as this may precipitate a gout attack.27 In the recommended low-purine diet, consumption of red meat and shellfish is restricted,17 whereas consumption of soy, nonfat milk and other low-fat dairy products, cherries and other fruits, and increased vegetable protein is encouraged.31,37 Consumption of alcohol, especially beer and fortified wines, should be limited.27,47
Avoiding trauma to joints affected by gout (including the stress of bearing excess weight) can help patients limit future attacks.7,27
CONCLUSION
Patients with gout often have the characteristic presentation of an acutely tender, inflamed joint, but since gout is a systemic disorder, the clinician must also consider the possibility of gout in almost any organ system. Gout is a common disease, and its diagnosis can alert the astute clinician to investigate for certain metabolic disorders requiring intervention. Hyperlipidemia, metabolic syndrome, hypertension, chronic kidney disease, obesity, cardiovascular disease, and diabetes are all conditions associated with gout.
Recognizing the opportunity to offer preventive care measures and recommend lifestyle modifications to the patient with gout allows the clinician to play an important role in the patient’s care.
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