eMedicine Specialties > Ophthalmology > Metabolic Disorders
Gout: Treatment & Medication
Updated: Feb 19, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
For urate crystals within the ocular tissue, treatment is directed at reducing both hyperuricemia and ocular inflammation.
Diet
Reduction of purine intake in the diet can moderate both the frequency and the severity of attacks of gout.
Medication
Treatment involves hydration, colchicine for prevention and acute treatment, nonsteroidal and steroidal anti-inflammatory drugs, uricosuric agents (eg, probenecid), and antihyperuricemic drugs (eg, allopurinol), which are effective in inhibiting xanthine oxidase, the enzyme that catalyzes the oxidation of hypoxanthine to xanthine and xanthine to uric acid.
Anti-inflammatory agents
Modify the immune system to diverse stimuli.
Colchicine
Decreases leukocyte motility and phagocytosis in inflammatory responses.
Adult
1-1.2 mg PO qd for acute attacks of gouty arthritis; 0.5-0.6 mg PO qd as maintenance dose
Pediatric
Not established
Sympathomimetic agent toxicity and effect of CNS depressants are significantly increased with colchicine
Documented hypersensitivity; severe renal, hepatic, GI, or cardiac disorders; blood dyscrasias
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Risk of renal failure, hepatic failure, permanent hair loss, bone marrow suppression, numbness or tingling in hands and feet, disseminated intravascular coagulopathy, and decreased sperm count
Uricosuric agents
Inhibit renal tubular reabsorption of urates, causing increase in urinary excretion of urates.
Probenecid
The generic name is 4-[(dipropylamine) sulfonyl)] benzoic acid. Inhibits tubular secretion of penicillin, and usually increases penicillin plasma levels by any route the antibiotic is given. A 2-fold to 4-fold elevation has been demonstrated for various penicillins. Used in treatment of hyperuricemia associated with gout and gouty arthritis. Also used as an adjuvant to therapy with penicillin or ampicillin, methicillin, oxacillin, cloxacillin, or nafcillin, for elevation and prolongation of plasma levels by whichever route the antibiotic is given.
Adult
0.5 g PO qd
Pediatric
Not established
Salicylates at high dosages, and nitrofurantoin, may decrease effects of probenecid; probenecid increases levels/toxicity of methotrexate, beta-lactam antibiotics, acyclovir, thiopental, clofibrate, dyphylline, pantothenic acid, ketorolac, benzodiazepines, rifampin, sulfonamide, dapsone, zidovudine, sulfonylureas
Documented hypersensitivity; known blood dyscrasia or uric acid kidney stones; coadministration of ketorolac as levels/toxicity of ketorolac are significantly increased
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Crosses placental barrier; use of any drug in women of childbearing potential requires anticipated benefit be weighed against possible hazards; caution in history of peptic ulcer
Allopurinol (Zyloprim)
Inhibit xanthine oxidase, the enzyme that synthesizes uric acid from hypoxanthine. Reduces the synthesis of uric acid without disrupting the biosynthesis of vital purines.
Adult
200-400 mg/d PO in divided doses
Pediatric
<10 years: 10 mg/kg/d PO divided bid/tid; not to exceed 400 mg/d
>10 years: 200-400 mg/d PO
Alcohol decreases effects; increases incidence of skin rash when used concurrently with ampicillin and amoxicillin; large amounts of vitamin C acidify urine and may cause kidney stone formation; allopurinol inhibits metabolism of azathioprine and mercaptopurine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for use in asymptomatic hyperuricemia; reduce dose in renal insufficiency; monitor liver function and perform complete blood counts before initiating therapy and periodically thereafter
Febuxostat (Uloric)
Xanthine oxidase inhibitor. Prevents uric acid production and lowers elevated serum uric acid levels. Indicated for long-term management of hyperuricemia associated with gout.
Adult
40 mg PO qd initially; after 2 wk, if serum uric acid levels are not <6 mg/dL, increase to 80 mg/d
Pediatric
Not established
Coadministration with xanthine oxidase substrate drugs (eg, azathioprine, mercaptopurine, theophylline) may increase plasma concentration of these substrates, resulting in toxicity
Documented hypersensitivity; coadministration with azathioprine, mercaptopurine, or theophylline
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increased gout flares frequently observed during initiation of therapy (use prophylactic therapies such as NSAIDs or colchicine); higher rate of thromboembolic events observed in patients treated with febuxostat compared with allopurinol in clinical trials (monitor for signs and symptoms of MI and stroke); may increase liver transaminase levels; common adverse effects include nausea, arthralgia, and rash
More on Gout |
| Overview: Gout |
| Differential Diagnoses & Workup: Gout |
 Treatment & Medication: Gout |
| Follow-up: Gout |
| References |
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References
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Coassin M, Piovanetti O, Stark WJ, et al. Urate deposition in the iris and anterior chamber. Ophthalmology. Mar 2006;113(3):462-5. [Medline].
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Margo CE. Use of standard hematoxylin-eosin to stain gouty tophus specimens. Arch Ophthalmol. Apr 2004;122(4):665. [Medline].
Mcwilliams JR. Ocular findings in gout; report of a case of conjunctival tophi. Am J Ophthalmol. Dec 1952;35(12):1778-83. [Medline].
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Wyngaarden JB. Gout. In: The Metabolic Basis of Inherited Disease. 1966:667-728.
Further Reading
Keywords
gout, uric acid, urate crystals, ocular tissue, kidneys, kidney stones, urinary collecting system, joint inflammation, joint destruction, tophus, tophi, alcohol, uric acid salts, uric acid metabolism, uric acid nephropathy, chronic tophaceous gout, tophaceous gout, gouty arthritis, primary gout, secondary gout, acute gout, chronic gout, polyarticular gout, hyperuricemia, acute monoarticular arthritis, polyarticular arthritis
