Gout: When is long-term treatment with medication suitable?

Treatment with medication is especially recommended if

• gout attacks have become frequent or are very distressing,
• joint damage is already visible in x-rays,
• tophi have already formed, or
• increased uric acid levels have caused kidney stones.

Treatment with medication may also be recommended if changes to your diet are not enough to lower the uric acid levels, or if they are very high.

If someone has had a gout attack for the first time, it’s not clear whether treatment to lower uric acid levels makes sense. Some people don't have any more problems after their first attack, while others only have them very rarely. That's why some medical societies don’t recommend starting treatment with medication right away.

It is not always clear what’s meant by "frequent" gout attacks. Usually, it means more than one or two gout attacks per year. Other factors that play a role include the how severe the attacks are and how well the medication for lowering uric acid levels is tolerated. And some people don't want to take tablets every day. Others may be more concerned about the long-term effects of gout, and find peace of mind in taking medication.

The drug allopurinol is the most commonly used uric-acid-lowering medication. It restricts the breakdown of purines and so reduces uric acid levels. The medication is taken after a meal with plenty of fluids.

It is recommended that you start treatment with a low dose of 100 mg, which is gradually increased until uric acid levels are below 387 micromoles per liter (µmol/L), or 6.5 milligrams per deciliter (mg/dL). If the levels go above that limit, uric acid crystals may form in the blood.

For people with mild gout, a dose of 200 to 300 mg allopurinol per day is usually enough. 400 to 500 mg may be needed to treat severe gout. The maximum dose is 800 mg per day, but that is only rarely needed.

After the treatment has been started, doctors will first check every three months to see whether the uric acid levels are low enough to stop crystals from developing. Less frequent check-ups, for example once a year, are enough at a later stage.

If treatment with allopurinol doesn't reduce uric acid levels enough, febuxostat is an option. It works in a similar way. Febuxostat is not the first-line treatment – one reason for this is that studies suggest it may increase the risk of fatal cardiovascular diseases somewhat more than allopurinol does.

Medications such as probenecide and benzbromarone from the uricosuric group are another treatment option. They work by increasing the amount of uric acid expelled by the kidneys. They can be taken in addition to allopurinol, but are only prescribed very rarely.

Allopurinol and febuxostat are very effective at reducing uric acid levels. Studies on these medications showed that most participants were able to lower their uric acid levels to under 387 µmol/L (6.5 mg/dL).

Most experts believe that taking these medications can successfully prevent complications of gout. That wasn't tested enough in the studies, though. So it's not possible to say exactly what people with gout can expect from long-term treatment with these medications – for instance, how many gout attacks can be avoided or how well the treatments can prevent joint damage.

Especially during the first few months of treatment, uric-acid-reducing medications may even increase the risk of gout attacks. The reason for this is that any uric acid crystals already present only break down gradually. When this happens, small particles of the crystals may be washed into the joint, where they then cause an inflammation that leads to a gout attack. That happens quite often. It is thought that it can take up to two years for the body to get rid of all uric acid crystals.

To prevent gout attacks during this time, low-dose colchicine is often also prescribed for the first six months. That effectively reduces the risk of those kinds of attacks. But even if one occurs, it's not necessary to stop taking the uric-acid-reducing medication.

Rashes are a possible side effect of allopurinol, occurring in an estimated 1 out of 100 people. Most of these rashes are mild and don't have any serious consequences. But in rare cases, a rash may be a sign of a hypersensitive reaction to allopurinol. That can lead to serious complications. People who have chronic kidney disease are especially at risk. So if they suddenly feel ill, develop a fever, cold-like symptoms or a rash, it's important to seek medical attention quickly.

There's not much good research on the side effects of febuxostat. The possible side effects include nausea and joint pain. Rashes and serious hypersensitivity reactions are also possible during treatment with febuxostat. Febuxostat is associated with a higher risk of cardiovascular disease than allopurinol is.