Continuous Gout Attack for Over 2 Months

There are three reasons for treating gout:

•    reducing the pain and inflammation caused by an acute attack
•    preventing future attacks
•    preventing joint damage or kidney problems

A consultant rheumatologist explains what long-term treatment for gout does, and why it is important.

A consultant rheumatologist explains what long-term treatment for gout does, and why it is important.

Long-term treatment of gout aims to reduce uric acid levels; the reason for this is that we know that if we can reduce uric acid levels we can stop acute attacks of gout from happening, we can prevent joint damage from happening in the long term, and we can also cause tophi - which are the deposits of uric acid sometimes found under the skin - we can cause those to shrink and eventually go away. If gout is only treated by treating symptoms that occur during the attack of gout, then we don't get rid of the crystals and hence those crystals can still go on to cause long term problems.

Reducing uric acid levels in the long term is best achieved by a combination of things that people can do for themselves, and drug treatment. Some people do get gout because they're overweight, or because they drink too much alcohol, particularly beer, or because they eat too much of certain types of food, such as red meat or seafood. And so for those people reducing those things might help, but for most people who have gout that doesn't have any effect. And in fact, unfortunately, we know that for most people with gout we don't lower their uric acid level enough without drug treatment. The most commonly used treatment for gout in the long term is allopurinol, and allopurinol is a very safe treatment, which doesn't cause many people to have health-related problems.

People who only have occasional attacks of gout, for example an attack every few years, might only need treatment to deal with these attacks (For more see 'Treating the pain and inflammation of attacks'). However, it is recommended that GPs and/or rheumatologists discuss long-term treatment with everyone who has gout*. People who have more frequent attacks may need daily medication for the rest of their lives to reduce the amount of uric acid (urate) in their blood and prevent further attacks or joint damage.

Carole's attacks were becoming more frequent. She started on a low dose of allopurinol and now takes 300mg daily. Her uric acid levels are well within the normal range now.

Carole's attacks were becoming more frequent. She started on a low dose of allopurinol and now takes 300mg daily. Her uric acid levels are well within the normal range now.

Age at interview: 64

Sex: Female

Last year I was getting too many instances and it was spoiling things because I have a hobby that I enjoy, and if I'd got gout I couldn't pursue it until the gout had gone. And I actually came round to thinking that I needed to do something more about it than just trying to manage my diet and dealing with episodes when they occurred.

And have you done anything about that yet, then?

Yeah. Went to see my doctor probably this sort of time last year. I can't quite be certain. Probably March, April time. And I agreed to go on to allopurinol gout medication, although we didn't go for the maximum dose to start with - started on a low dose.

I was still getting attacks. I went for a six-monthly review with my GP. It'll be seven weeks ago now. And I was chatting to him, telling him how I'd been, and I said to him, "I am still getting gout." And I think I'd said to you I'd had probably three or four attacks from somewhere like last autumn through to when I went to see the doctor. Well, my understanding was that the idea of going on the allopurinol is not to have any attacks. So what he did - I was on 200 milligrams - so he upped the dose to 300mg but asked, as I say, for a blood test in six weeks to see what had happened. And I had that test last week and was told that the uric acid levels were now within a normal range, which I don't think they've ever - well, they haven't been for as long as I can remember. However I did have an attack again after I'd seen my GP seven weeks ago, but I was - or I did take anti-inflammatories as well, because I thought, "Well, we've upped the dose by 30, 33%. I suppose there's a chance it might kick off and make things worse." And I had a mild attack. I knew I'd got gout, but it didn't actually stop me doing anything except make it a bit painful to get my shoe on and bend - because it was in the little - the base - the joints in my little toes in - on one foot. And, as I say, I knew I'd got it, but it didn't actually stop me walking or doing anything. It was just a little bit painful; nothing like it might have been without medication or without the anti-inflammatories. And, touch wood, I haven't had it since.

How does ongoing treatment prevent attacks and long-term damage?

Long-term joint damage and formation of tophi (small white lumps under the skin) can be caused by a continued build-up of uric acid crystals. Crystals can damage the cartilage and bones, leading to long-term arthritis. If people do not take long-term treatment for gout, uric acid can sometimes form kidney stones. The drugs used to relieve symptoms of a gout attack do not get rid of uric acid crystals in the joints or reduce the level of uric acid in the blood, but ongoing treatments, like allopurinol, can do this.

Harry did not realise that gout was causing him long-term joint damage. He now takes febuxostat every day and has noticed improvements in some joints.

Harry did not realise that gout was causing him long-term joint damage. He now takes febuxostat every day and has noticed improvements in some joints.

Age at interview: 78

Sex: Male

I thought, "Yeah, it's something that is painful, it is something that comes and goes, and if I take tablets it will go away", and I was prepared to do that, just to take tablets to ease the pain. Don't realise when you get it, the effect that it's having on you, and I had quite some severe attacks in my hands as well as my feet. And that's left me now with permanent damage which I didn't realise was going to happen. It was just, "Oh, it'll go away", and yes the pain goes away, but the effects of the attacks of the acid and the crystals doesn't go away, it remains there. Having said that, since I've been on febuxostat, the swellings have gone down. You wouldn't believe the difference in - particularly in my right big toe, how much it's decreased in size, over the last year and a half, it's - it's virtually back to normal. But my hands are still not right. No. Maybe they'll go. Bearing in mind that I had gout for 40 odd years, it's not surprising really that some of the effects of that gout are going to take a long time to go away, but hopefully they will go away.

Reducing the levels of uric acid prevents new crystals from forming. It also slowly dissolves the crystals that are already there. It can take up to 2 years of daily medications to completely clear the body of crystals, and then further attacks of gout and joint damage are unlikely. Even when the crystals have been dissolved, long-term treatment is still needed once a day to keep levels of uric acid within the normal range and prevent new crystals from forming.

Starting long-term treatment

Ongoing treatment is usually recommended for people who are having frequent attacksor have complications of gout: people who have tophi, kidney stones or signs of joint damage, and people who have very high levels of uric acid in their blood. Currently there is no expert agreement on how frequent attacks need be before long-term treatment is recommended. Sometimes it might be suggested after one attack, and in other cases GPs or specialists may prefer to wait until two or more attacks have occurred over a 12 month period. However, it is recommended that GPs and/or rheumatologists discuss long-term treatment with everyone who has gout*.

People sometimes find that starting long-term treatment triggers an attack. This is because the crystals start to dissolve and become smaller, and can then move around more easily. Daily non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine can be taken to supress inflammation while the ongoing treatment begins to reduce the levels of uric acid. It can take up to 2 years for crystals to be completely cleared from the body, so people may continue to have attacks during this time.

John's had attacks less often in the last 18 months since he has been taking 300mg of allopurinol.

John's had attacks less often in the last 18 months since he has been taking 300mg of allopurinol.

Since I've been properly on the allopurinol which is probably 18 months now - I would have thought, it's got to be, the full dose - the attacks have been getting less and less and less, thankfully, and less. And, like I say, it was last year, when I had a really nasty attack. Perhaps in October time, will it be? I think it's probably October time. You get the odd twinge, you know, like I say this little finger, hurts now and again, but, that's, and the knee will ache a little bit. But, whether it's the gout, I don't think it is, or my knee.

Two long-term medications for gout are allopurinol and febuxostat.

Allopurinol

This is the most commonly used drug. It is usually taken once a day, and works by lowering the amount of uric acid produced by the body. After uric acid levels are measured, people are usually prescribed a low dose to start with. This is because, if levels of uric acid are reduced too quickly, an attack can be triggered. Starting at a low dose also reduces the risk of unwanted side effects (for more see 'Side effects of gout medication').

A consultant rheumatologist explains why starting allopurinol can trigger attacks and why it can take up to two years for attacks to stop.

A consultant rheumatologist explains why starting allopurinol can trigger attacks and why it can take up to two years for attacks to stop.

People often find that when they start to take allopurinol, that they can get an attack of gout. The reason that this happens is because crystals of uric acid are normally found tightly packed within the cartilage that lines the bones, and when they start taking allopurinol, their uric acid is lowered so the crystals start to dissolve and start to become smaller – meaning that they can be more easily shaken loose into the joint, which is when that leads to inflammation and to an attack of gout. So although people often see having an attack of gout after starting allopurinol as a side effect of allopurinol, and clearly that's something that from the patient's point of view is unwanted, we should actually be seeing attacks like that as a sign of successful treatment – a sign that treatment is working – because it is telling us that uric acid levels are starting to be lowered, and that crystals are starting to dissolve. This also explains why people can continue to have attacks of gout for up to two years after starting allopurinol, because it takes up to two years for the crystals to dissolve completely.

Uric acid levels will then be tested after about a month, and the dose will be increased by 100mg if the levels have not come down to within the normal range. This process of checking uric acid levels and increasing the dose may need to happen several times to get to the dose that is enough to keep the uric acid levels low enough (below 360µmol/L). Many people need 400-500mg a day. The maximum dose is 900mg a day. Allopurinol is available as 100mg and 300mg tablets, so even if you are on a higher dose you should not have to take many tablets.

Ray takes allopurinol every day. The tablets are small and he does not mind taking them because they have stopped his attacks.

Ray takes allopurinol every day. The tablets are small and he does not mind taking them because they have stopped his attacks.

Age at interview: 67

Sex: Male

They did say that, once I went on allopurinol, I would be on it for the rest of my life, but I mean it's one tablet a day. There has been occasions when I've missed, but it's very, very rarely that I miss more than a couple of days. If I've missed it, it hasn't caused any problems. But I'll, you know, I'll quickly get back on it, I remember what the pain was like. It hurts [laughs].

The fact that I was in my 40s and they say you take this tablet every day for the rest of your life, but it's one tiny tablet once a day not like, you know, people that's on all these drugs having to take 10 and 20 tablets a day. I was having to take one to solve the problem and, you know, so it's nothing is it, you drink more cups of tea, more cups of coffee, just have one tablet that's it, you know, brilliant.

Once uric acid levels are within the normal range and attacks have stopped, the tablets should be continued every day. Blood tests should be done every one or two years to make sure that the uric acid levels are still low enough (less than 360µmol/L).

A consultant rheumatologist explains why it is important to monitor uric acid levels.

A consultant rheumatologist explains why it is important to monitor uric acid levels.

Once gout is diagnosed it's important to check for other conditions that are linked with gout, such as diabetes, high cholesterol, or kidney disease. In terms of keeping an eye on people once they're on treatment for gout, it's important to check uric acid regularly, as that gives a marker of how the treatment is working, and we aim as doctors to make the uric acid level quite low, so we monitor this. It's also important to check kidney tests and these are done usually through blood tests. We know that people who have gout are more likely to have other health conditions, such as heart disease, and so people with gout are often invited for extra health checks, to check things like blood pressure and to screen for things like diabetes.

Long-term treatment is not usually started during an attack because the drug could make the attack worse. It also means that the pain people have during an attack does not affect their decisions about treatment options. Ongoing treatment is usually started between 2-4 weeks after an attack has ended, although a research found that people who started allopurinol during an attack had no more pain than those who did not [Taylor, Mecchella, Larson, Kerin and MacKenzie, 2012].

John was worried about the idea of allopurinol triggering an attack. He is waiting for a few clear weeks without an attack before he starts taking it.

John was worried about the idea of allopurinol triggering an attack. He is waiting for a few clear weeks without an attack before he starts taking it.

Age at interview: 57

Sex: Male

What are your thoughts about taking allopurinol?

[Laughs] I think he frightened me when he said it'd give me a bout of gout first. Taking allopurinol apparently kicks in a gout attack and then from then on it's gone, or so they say. But yeah I'd give it a go. I've actually had a prescription for it, but then I had a gout attack. The week I got – the day I got a prescription for it, on a Wednesday, but then on Thursday I was laid up in bed with damned gout. So I thought, "Well, there's no point in taking it. This is just wasting money."

Is that what the doctor told you to do?

No, I decided – I went back to the doctor and said, "Look, I won't take it because I've got an attack. I don't want to waste the money."

If people have side effects from allopurinol such as a rash, nausea, headaches or indigestion, they should stop taking the tablets and ask their doctor for advice. Lower doses, and more caution when increasing doses, are needed for people who have kidney problems because they are at more risk of side effects. Allopurinol can also affect some other tablets, like warfarin and azathioprine, so people must tell their doctor if they are taking these drugs.

Febuxostat

Febuxostat is the main alternative to allopurinol. Febuxostat is suitable for some people who cannot take allopurinol, and it does not affect warfarin. It is not recommended for some people with heart problems, people who have had organ transplants or people who are taking azathioprine (used to treat a variety of long-term conditions, such as inflammatory bowel disease).

Harry had an allergic reaction to allopurinol. He now takes febuxostat and has no problems.

Harry had an allergic reaction to allopurinol. He now takes febuxostat and has no problems.

Age at interview: 78

Sex: Male

And to start off with I was getting attacks two, two and a half year intervals. As time went on, from '66, the attacks got a bit more severe, and a bit more frequent, until ultimately I had to go back to the GP, and we tried to get on to some sort of permanent medication. And the medication, I've forgotten the name of it again, didn't suit me, I was totally allergic to it, and I only ever had two of these tablets before I had this violent allergic reaction to it, and had to stop taking it. From then on it was a question of taking painkillers of all sorts of varieties, and different tablets such as diclofenac, I had probenecid, I had all sorts of tablets to try and keep it under control, nothing seemed to work, it was always just a firefighting exercise, that I'd get an attack, I would take tablets to get rid of it, and sit back and wait for the next one. At the end I suppose I was getting an attack about every six months, until 2010, when I went to see a specialist in this field and we sorted out febuxostat, which I now take, along with the colchicine, I take one colchicine each day, and since middle of 2011, I haven't had an attack of gout at all. Seems to be well under control. And - if that's the regime that it requires to keep it under control, then I will swallow these three tablets each morning for the rest of my life and be quite happy to do it.

Other options

Low doses of colchicine can be taken every day to reduce the tendency for attacks. However, this will not get rid of crystals or prevent long-term joint damage because colchicine does not reduce the levels of uric acid in the blood.

Other drugs can be used to reduce uric acid levels for people who cannot take allopurinol or febuxostat. These drugs increase the amount of uric acid that is removed from the body in urine. They include sulfinpyrazone, probenecid and benzbromarone. It is best for people who cannot take allopurinol or febuxostat to discuss these options with a specialist.

(For more see 'Decisions and feelings about treatments'.)

*EULAR guideline – Richette et al Ann Rheum Dis 2016

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Last reviewed December 2016
Last updated December 2016

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Source: https://healthtalk.org/gout/long-term-treatment-to-lower-uric-acid-and-prevent-gout-attacks-and-long-term-problems

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