The Rational Management of Hyperuricemia and Gout

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 The Rational Management of
Hyperuricemia and Gout

Prof. Emeritus, Lt. Gen Mahmud Ahmad Akhtar
Former Surgeon General Pak Army

Drugs are used quite often irrationally in Pakistan, not only by the general practitioners /family physicians but also by many specialists. One major factor is the prevailing therapeutic deficit in the knowledge of medical practitioners due to non existence of the departments of clinical therapeutics/ clinical pharmacology.  This clinical specialties like cardiology, gastroenterology etc. is essential component of the teaching hospitals and also of general hospitals in UK as recommended by the World Health Organization experts committee.  The other reason is unbridled aggressive promotion of drugs by the pharmaceutical companies due to the lack of overseeing of the drug watch-dog body-The “Drug RegulatoryAauthority of Pakistan (DRAP)” which also lacks the expertise of clinical pharmacology/ clinical therapeutics and also clinical pharmacy which are the major component of international drugs regulatory bodies. Pakistan’s common devastating disease, corruption prevailing all around – kickbacks the common mode, being used by the promoters of drugs.

Hypo-uricemia

It should be absolutely clear to every health care-taker that asymptomatic hyper-uricemia should not be treated with drugs, which have many side effects including fatal hypersensitivity reactions. Unfortunately hypo- uricemic drugs, the old Allopurinal and the new arrival Febuxostat is particularly promoted very aggressively. It is well-known saying that the old drugs accumulate the list of side- effects while the new ones earn publicity through pharmaceutical companies. Luxurious dinners at five star hotels etc, the expenses are added to the cost of medicines which patients have to endure. However the list of side-effects of Febuxostat as reported in the recent British National Formulary edition has reached over thirties including fatal hyper sensitivity reactions belying the claims of the pharmaceutical companies is more than ten times of the Allopurinol. Hyperuricemia is a lifelong disorder; therefore the cost makes huge difference. Irrational use of these drugs leads to not only having harmful toxic effects but also loss of meager financial resources of the patients and of the poor debt -ridden Nation.

Hyperuricemia is wrongly being promoted as the risk factor for heart attacks, HTN, metabolic disorders, strokes etc.  Hyperuricemia has an association with the metabolic disorders but is not the causative factor. This vital point should be well-ingrained in the minds of the medical practitioners. Furthermore aches and pains which are quite common are touted by the pharmaceutical companies to be the cause of symptoms-ignorant or corrupt practitioners are frequently misusing the drug.

Indications of urate lowering therapy

  1. Frequent and disabling gouty attacks often defined as two or three flares annually.
  2. Chronic gouty diseases clinically or radiologically evident joint erosions.
  3. Tophaceous deposits; subcutaneous or intraosseous.
  4. Gout with renal insufficiency.
  5. Recurrent kidney stones.
  6. Urate nephropathy.
  7. Urinary uric acid excretion exceeding 1100mg/ (6.5mmol) when determined in men younger than 25 years or in pre- menopausal women.

The drugs used for lowering serum uric acid are Allopurinol and the ‘Febuxostat’ a new drug. Allopurinol, a xanthine – oxidase inhibitor an enzyme converting nucleo-proteins to uric acid are Allopurinol costs a fraction of the cost of Febuxostat. The cost of full dose treatment with Allopurinol is Rs. 5 per day while with Febuxostat is about Rs. 40 per day. As the treatment is life long the difference in cost is at astronomical. It should be noted that Allopurinol is included in WHO’s “Essential Medicine List” and not Febuxostat.

Acute Gout

The Treatment of acute gout consists of terminating the acute attack and undergoing long term therapy to avoid chronic arthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are quite effective in terminating acute attacks swiftly. All NSAIDs are equally effective. Cost Effective preparations should be used. Naproxen 500mg BD, lowering dose with improvement, 5-10 days therapy is quite effective. Indomethacin 100 mg stat, 50 mg 06 hourly till the pain subsides in 5-10 days usually is used. Patients allergic/intolerant to NSAIDs,having acute GI hemorrhage, peptic ulcer, renal insufficiency and heart failure are advised to avoid the use of NSAIDs. PPIs may be prescribed for those suffering from dyspeptic symptoms.

Colchicine Therapy

Earlier high dose colchicines therapy was used to treat acute attack of gout. Due to onset of side-effects like acute diarrhoeas, its use was replaced with NSAIDs. Recently low dose cholchicine therapy in patients of acute onset used within a few hours, two tablets of 0.6mg colchicine(total 1.2 mg) followed by one tab after one hour have been found to effectively terminate acute attacks without any significant side-effects.

Corticosteroids

Those patients who cannot take NSAIDs and colchicine or colchicine is ineffective may be treated with corticosteroids. Prednisolone tablet 20 mg BD, 5-10 days course with abrupt termination is quite effective or a longer tapering off dose of 10-14 days may be used. A short course therapy is more suitable. Intra-articular injection of corticosteroids like Triamcinolone20-40 mg quickly terminates an acute attack. It should be rarely used. Intra-articular steroid injection can flare up a purulent arthritis. Therefore before injecting corticosteroid, one should be sure that there is no purulent infection of joint.

Patients having treatment for acute gout who are advised prolonged hypo-uricemic therapy should not be placed on hypo-uricemic drugs during acute attacks. Hypo-uricemic drugs should be started after the acute attack has completely subsided. And then they should be started in a low dosage with cover of colchicines in low dosage 1-2 tabs a day in order to avoid the occurrence of acute attack of gout, which occurs due to rapid fluctuations in serum uric acid levels. The dose of hypo-uricemic drugs should be gradually increased. Going through the prescriptions, it is my common finding that quite often hypo-uricemic drugs are started in the acute stage often in patients who don’t need it. The goal of therapy is to keep serum uric acid around 6.0 mg-in some patients around 5.0 mg to avoid recurrence of acute attacks. Although low dose aspirin therapy used for the prevention of heart attacks, strokes etc. increase serum uric acid, the therapy should not be stopped for its over-riding life saving benefits and very mild increase of uric acid.

Preventive Measures

Prevention is not only better than cure but it is the only cure, for the real cure obesity should be treated; particularly mid-abdominal girth should be kept below 351/2 ‘’ in males and 311/2 ‘’ in females. Using low fat diet, avoiding sugars, corn syrups, using at least 5-8 portions of vegetables/fruits, whole grains, avoiding organ meat, taking low purine diets particularly of animal origin, using preferably plant based oil. Zero tolerance for trans-fatty acids, low salt diet and intake of water should be at least 2-3 liters per day with good urinary output and avoiding prolonged fasting. A regular schedule of physical exercise/sports should be a part of the life style therapy.

Common Pitfalls

Asymptomatic hyperuricemia is irrationally treated with drugs on a large scale causing un-necessary side-effects & loss of finances. For hypo-uraecimic treatment, Febuxostat which costs about ten times of Allopurinol, misused as the first line drug. It should only be used for those patients who are intolerant of Allopurinol.Aches and pains are very common due to multiple, quite often due to minor causes, hyperuricemia is wrongly attributed to be the cause, consequently hypouricemic drugs are misused.

Conclusion

Asymptomatic hyperuricemia should not be treated. It is not a risk factor like cholesterol/lipids. Acute attacks of gout should be treated with a course of cost-effective NSAIDs or in suitable patients with a low dose colchicine therapy. Those who are intolerant to these drugs or have contraindications may be treated judiciously with corticosteroids therapy.