Two Ways to Prevent Gout Flares and Complications
Gout attacks are no fun. They're downright painful and disruptive. And they're certainly not something you want to experience often. Reducing future attacks of gout and its complications — like kidney stones, heart disease and broken bones — is the goal of treatment.
There is no cure for gout, but taking your preventive medication as prescribed will stave off flares and can help prevent complications. Taking medication as prescribed and addressing lifestyle habits is the way to reach your gout treatment goal.
You have several medication options to treat gout pain and inflammation. There’s also a robust pipeline of newer drugs that may be even more effective than existing ones, with fewer side effects. Take a look.
OTC Pain Relievers
Gout attacks or flares may start treatment using over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen. These drugs relieve pain but do not lower levels of uric acid.
In other words, pain relievers treat the symptoms of gout, not its root cause.
Side effects of these drugs include stomach pain, heartburn, and an increased risk of bleeding. Do not take NSAIDs if you have kidney disease, stomach ulcers, or certain heart conditions.
Colchicine
Colchicine does double duty for your gout, not only treating pain but also helping to hold off future gout flares. This drug keeps uric acid crystals from causing inflammation.
You can take small amounts of it regularly to prevent gout attacks or large amounts during a short period of time to treat a current attack. High doses may cause diarrhea.
Lower doses seem to keep diarrhea at bay without compromising colchicine's effectiveness. Your doctor will adjust your dose if you have kidney disease.
Colchicine may also interact with other medications, including the antibiotic clarithromycin. Make sure to share your full health history with your doctor to avoid unnecessary complications.
Corticosteroids
Steroids can help cool inflammation and reduce swelling and pain if you’re having a flare-up of gout. You can take them as a pill or via injection. Injections may be used if your gout is limited to just one joint.
These medications have their share of risks, including bone thinning, mood changes, a rise in blood sugar levels, and infection. When steroids are taken only for short periods of time, these risks are low.
Uric Acid-Lowering Therapies
Uric acid-lowering therapies help prevent gout attacks by lowering levels of uric acid in your body. These drugs are taken over the long term because gout is a chronic disease that requires long-term treatment.
But the sudden drop in uric acid can also cause existing crystals to break down and disperse into your joints. The tiny crystals can trigger an inflammatory response and a flare of gout after you first start your medication.
If this happens, keep taking your medicine and let your doctor know about the flare. Uric acid lowering medicine categories include:
- Xanthine oxidase inhibitors, which block uric acid production
- URAT1 blockers, which help the kidneys excrete uric acid
- Uricase agents, which break down uric acid into a water-soluble form that the kidneys can excrete more easily
Xanthine oxidase inhibitors
Allopurinol (Lopurim, Zyloprim) is the most common uric acid-lowering drug prescribed to prevent gout. It blocks an enzyme called xanthine oxidase, which prevents the breakdown of purines.
When purines are not broken down, your body’s total amount of uric acid goes up. This drug works if you make too much uric acid or if you have trouble excreting it.
Within one week of your first dose, your uric acid levels will go down. For some people, the rapid change in uric acid level may raise the risk of a gout attack in the early days.
Febuxostat (Uloric) lowers uric acid levels in the same way that allopurinol does: inhibiting xanthine oxidase. It might be prescribed if allopurinol didn’t work for you or you aren’t able to take allopurinol.
But it might not be a good treatment option if you have heart disease. Talk to your doctor about all of your conditions.
Like allopurinol, starting febuxostat tablets may trigger a gout attack. Your doctor may recommend adding another medication for the first six months after starting febuxostat to help avoid gout flares.
URAT1 blocker
Probenicid (Probalan) prevents gout attacks. It works by helping your kidneys excrete more uric acid. That means there’s less uric acid in your body to form painful crystals that cause inflammation.
It’s considered a non-specific URAT1 blocker. It may be combined with colchicine. Side effects may include headache, upset stomach, vomiting, and dizziness.
Uricase agent
Pegloticase (Krystexxa) reduces uric acid levels quickly and may also shrink tophi faster than any other gout drug available today. It’s given by an infusion over two hours.
The problem? It can also cause you to develop antibodies, which means the drug will eventually stop working for you.
“If we can prevent antibody formation, it has been shown that the effectiveness of pegloticase is also much better maintained,” says Theodore R, Fields, MD, a rheumatologist at the Hospital for Special Surgery in New York City.
Adding medications such as methotrexate or mycophenolate mofetil to pegloticase can help prevent antibodies from forming. In 2022, the FDA approved the combination of methotrexate and pegloticase to block antibody formation.
Surgical Treatment
Untreated gout can raise your risk for complications such as permanent joint damage and chronic pain, the formation of tophi, and kidney problems, including painful kidney stones.
You can also get more frequent, longer, and more severe attacks that affect multiple joints. So gout can sometimes look like septic arthritis. Although not common, surgery does have a role in gout treatment.
New Treatments on the Horizon
The gout drug research pipeline is full. Some of the drugs are next-generation versions of existing gout medication, and others have all-new ways to address gout.
IL-1 blockers
Anakinra (Kineret) blocks interleukin (IL) 1-beta, which is a key inflammatory protein in gout. It is already approved to treat rheumatoid arthritis, and some doctors may use it “off label” for gout. “There’s a lot of interest in IL1 blockade, and some of the newer ones coming out look promising and possibly safer and more long-acting than the ones we already have,” Fields says.
Another IL-1 blocker, canakinumab (Ilaris), is now approved to treat gout attacks when other treatments haven’t worked or caused side effects. Like anakinra, it’s given by injection. The IL-1 inhibitor gout pipeline includes rilonacept, too.
Rilonacept is approved for treating infection in the tissue around the heart. It’s not approved by the FDA for treating gout, but is being studied. Studies show that it may reduce the pain of gout flare-ups and reduce how often gout flare-ups occur.
Medications that block the inflammasome
Several medications under study block the inflammasome, a group of proteins that work together to activate IL-1beta, which can stimulate gout flares. This will be an all-new class of drugs for gout. Examples include NLRP3 blockers such as dapansutrile, a pill that is currently being studied in clinical trials.
Next-generation xanthine oxidase inhibitors
Tigulixostat aims to inhibit xanthine oxidase activity to lower uric acid production and blood levels of uric acid. It’s currently being studied in clinical trials.
Nano-capsulated sirolimus plus pegadricase (NASP)
Nano-capsulated sirolimus plus pegadricase (NASP) is the next-generation version of pegloticase. This is similar to giving pegloticase with methotrexate.
Results of a 48-week study showed that uric acid levels dropped one week after the first infusion and stayed low. Infusions were given every four weeks. The FDA is reviewing the drug’s safety and effectiveness and should make a decision soon.
New URAT1 inhibitors
Pipeline gout drugs also target URAT1 by blocking the reabsorption of uric acid in the kidneys. This increases the excretion of uric acid and lowers blood levels.
Older drugs like probenecid are non-specific, which means it affects multiple targets in the body so there’s a higher chance of interactions. The newer URAT1 inhibitors are more focused. As a result, they may be more effective and safer.
There are many medications available to help you during a gout attack and to keep flare-ups at bay. Even better news: The pipeline is flourishing, and newer agents promise to work better, faster, and with lower risks of side effects.
Show Sources
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SOURCES:
Theodore R, Fields, MD, rheumatologist, Hospital for Special Surgery, New York, New York.
Mayo Clinic: “Rilonacept (subcutaneous route).”
National Library of Medicine: “Probenecid.”
Hospital for Special Surgery: “Gout in depth: Risk factors, diagnosis, and treatments."
American Academy of Orthopaedic Surgeons: “Surgical Treatment.”
Nature Reviews: Rheumatology: “Mechanisms and rationale for uricase use in patients with gout."
Arthritis Research and Therapy: “Interleukin-1β inhibitors for the management of acute gout flares: a systematic literature review.”
MedlinePlus: “Canakinumab injection,” “Pegloticase injection,” “Febuxostat,”
Lancet Rheumatology: “Dapansutrile, an oral selective NLRP3 inflammasome inhibitor, for treatment of gout flares: an open-label, dose-adaptive, proof-of-concept, phase 2a trial.”
Arthritis & Rheumatology: “Serum Urate-Lowering Efficacy and Safety of Tigulixostat in Gout Patients With Hyperuricemia: A Randomized, Double-Blind, Placebo-Controlled, Dose-Finding Trial.”
American College of Rheumatology: “Nanoencapsulated Sirolimus plus Pegadricase (NASP) Demonstrates Long Term Efficacy and Safety in Patients with Uncontrolled Gout: Results from the 24-week Double-blind Extension of the Phase 3 DISSOLVE I Study,” “Rilonacept (Arcalyst).”
