Gout Treatment. Posted by Dr. Badsha, Rheumatologist, Dubai, United Arab Emirates

PHILADELPHIA -- Going beyond the recommended dosing of allopurinol (Zyloprim) to treat patients with gout may help prevent recurrence safely, researchers contended here.

"While allopurinol is the mainstay of treatment, physicians have concerns about increasing the dose above recommended guidelines particularly in patients with impaired kidney function, "said Lisa Stamp, MD, PhD, of the University of Otago in Christchurch, New Zealand.

"This has led to poor control of gout which causes significant pain, impacts on quality of life, and can lead to permanent joint damage," she said at the annual meeting of the American College of Rheumatology.

Stamp argued instead for a "treat-to-target" approach for urate lowering therapy.

She said using sufficient allopurinol to keep serum urate to less than 6 mg/dL may be a better strategy than persisting with doses perceived to be safe but which are inadequate to achieve the goals of treatment.

She explained that recommendations for allopurinol use are tied partly to kidney function. But these conservative doses may fail to achieve adequate serum uric acid reduction, she said.

Stamp and colleagues recruited 90 people with gout who were on a stable dose of allopurinol for at least one month. The average age of the participants was 58.3; 87.8% were male. At the initial visit, 52 participants had serum uric acid levels greater than 6 mg/dL, the critical level above which gout is more likely to occur.

For 45 participants their dose of allopurinol was increased anywhere from 50 to 400 milligrams above the recommended range. Of these, three developed rashes and discontinued the drug or went back to a lower dose, and six failed to attend follow-up appointments or developed intervening medical problems unrelated to gout.

Of the 36 patients who completed the 12-month study, 86% saw a drop in serum urate levels to 6 mg/dL or less.

"There was no increase in toxicity with higher doses of allopurinol in this cohort, including those with renal impairment," Stamp said. Three patients on high-dose allopurinol had rashes.

Baseline doses of allopurinol were about 35% higher in patients co-treated with furosemide (248 mg/day versus 180 mg/day in patients not given furosemide), Stamp reported.

But similar proportions of patients achieved the 6-mg/dL urate target whether they were on furosemide of not (72% versus 89%, P=0.24).

Increasing the dose of allopurinol above the recommended levels could help reduce gout attacks, agreed Eric Matteson, MD, of the Mayo Clinic in Rochester, Minn.

"The key message in this study is that in those patients who can tolerate the 300 mg dose of allopurinol, the dose can be safely pushed higher," Matteson said. "We may be far too conservative in treating these patients to prevent gout."

He noted, though, that 10% to 20% of people who are prescribed allopurinol cannot tolerate the drug because of adverse side effects.