Lowering Uric Acid Levels
Standard urate-lowering medicines are:
- Allopurinol – This is an oral prescription that helps lower serum uric acid levels. This medicine is also known by brand names Lopurin® and Zyloprim®. When started on this drug, your doctor will likely gradually increase the dosage to a standard prescription dose.
- Febuxostat – This is another urate-lowering therapy that can be prescribed under the brand name Uloric®. This medication is taken orally and decreases the body’s production of uric acid. It can be taken by people with mild to moderate kidney or liver disease.
Some general potential side effects of allopurinol are: changes in taste, diarrhea, indigestion and stomach pain or cramps. For febuxostat, some minor side effects are: changes in appetite, constipation or diarrhea, nausea, hot flush to face or skin, stomach upset or pain. It’s important that if they persist or there are questions, call a doctor.
Though only 1 in 1,000 patient cases, there is a more severe hypersensitivity reaction to allopurinol, with fever or rash that can cover the body and deterioration of liver and kidney function. At-risk patient populations (Han Chinese, Southeast Asians, and Koreans with kidney disease) can be screened for a genetic marker (HLA-B5801) that can predict this reaction. To alleviate this hypersensitivity, doctors will start a patient on a low dose with a step-up plan to the optimal medication dose.
Pain Management
There are several options given to get the pain under control. By mouth, they are typically taken while the gout flare lasts. It is important to take medications as prescribed to eliminate the inflammation. If experiencing stomach upset when taking medications, your doctor, or a practice nurse, will guide you on taking your medication with food or switching to another medication.
Standard medicines prescribed for pain and inflammation for gout are:
- Nonsteroidal anti-inflammatory drugs (NSAIDS) – Several—like Advil®, Aleve® and Motrin®—are available in over-the-counter dosing. Your doctor may also give you a prescription dose. Other brand-name NSAIDs include Celebrex®, Indocin®, Naprosyn® and Tivorbex®.
- Glucocorticosteroids – Cortisone can be taken orally or injected, and quickly suppresses the inflammation of an acute gout flare. It may be prescribed under the brand names Deltasone® (prednisone), Kenalog®-40 or Medrol®.
- Colchicine – This is usually most effective when taken within the first 12 hours of an acute flare; however, other medications may still be needed for treating pain. A common dosing schedule is to take two, 1.2 mg tablets together at once, then a third tablet one hour later, followed by one tablet 2-3 times per day over the next week. Patients may have side effects such as nausea, vomiting, abdominal cramps or diarrhea. Brand names include Colcrys® and Mitigare®.
It is important to note that gout flares often occur when a patient first starts taking medications to lower uric acid levels. Patients can help prevent flares when starting these medications by also taking low‐dose colchicine or NSAIDs. Often, doctors advise patients to keep taking colchicine in a low, preventive dose together with the uric acid-lowering medicine for at least six months.
If you are taking a uric acid-lowering drug, your doctor should slowly raise the dose and keep checking your blood uric acid levels regularly. Once your uric acid levels reach or drop below a healthy 6.0 mg/dL, crystals tend to dissolve and new deposits of crystals can be prevented.
Recurring Gout Medications
When traditional gout therapy to lower uric acid is not working, your doctor may increase medication dosage, add another medication to the traditional therapy or change the medication. All of this is done with the goal of bringing uric acid under control—because ongoing flares result from higher sUA level, and as the culprit in this disease, uric acid has to be reduced to stop flares.
When standard-of-care medications like allopurinol aren’t working, others will be introduced at this stage of gout disease. They are:
- Lesinurad – Taken orally, this medication should be taken in combination with another drug, such as Allopurinol or Uloric. Under the brand name Zurampic®, it treats high uric acid levels in people with gout who are already taking a urate-lowering therapy.
- Lesinurad + Allopurinol Fixed-Dose Combination – Taken orally, this medication treats high uric acid levels in people with gout who have not achieved target serum uric acid levels on allopurinol alone. A brand name is Duzallo®.
- Probenecid – Taken orally, this medication increases the kidneys’ ability to remove uric acid from the body. It is not recommended if there is a history of kidney stones or renal impairment. Two brand names are Benemid® and Probalan®.
Often, medications are prescribed in combination.
For example, lesinurad or probenecid, which block uric acid production, can be added to allopurinol or febuxostat, which helps the kidneys eliminate uric acid in urine. Doctors may also add 500 – 1,000 mg of vitamin C, which can also help eliminate uric acid. If a patient is already on a diuretic, then they may be switched to another to help uric acid elimination.
Side-effects
Some side-effects from lesinurad and probenecid may occur that usually do not need medical attention. They are: chills, heartburn, cough, diarrhea, fever, general feeling of discomfort or illness, loss of appetite and joint pain. These side effects may go away during treatment as your body adjusts to the medicine. Also, your doctor or practice nurse is able to advise on how to prevent or reduce some of these side effects. Always check with your doctor if side effects continue or are bothersome or if you have questions about them.
While gout is a lifelong condition, it can be managed – or even completely controlled – by sticking with a proper treatment plan that combines the right medication with diet and lifestyle changes. Because gout is associated with other serious health issues, an accurate diagnosis and ongoing management is critical.
If pain medication needs to be adjusted, your doctor will choose what is best from among these prescription and over-the-counter drugs.
- Nonsteroidal anti-inflammatory drugs (NSAIDS) – Several—like Advil®, Aleve® and Motrin®—are available in over-the-counter dosing. Your doctor may also give you a prescription dose. Other brand-name NSAIDs include Celebrex®, Indocin®, Naprosyn® and Tivorbex®.
- Glucocorticosteroids – Cortisone can be taken orally or injected, and quickly suppresses the inflammation of an acute gout flare. It may be prescribed under the brand names Deltasone (prednisone), Kenalog®-40 or Medrol®.
- Colchicine – This is usually most effective when taken within the first 12 hours of an acute flare; however, other medications may still be needed for treating pain. A common dosing schedule is to take two, 1.2 mg tablets together at once, then a third tablet one hour later, followed by one tablet 2-3 times per day over the next week. Patients may have side effects such as nausea, vomiting, abdominal cramps or diarrhea. Brand names include Colcrys® and Mitigare®.
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