Two habits undo gout treatment, and both are about what happens during an attack. The first is stopping urate-lowering therapy when a flare occurs. Established practice is to continue it through the attack: stopping and restarting causes the urate to swing, which provokes further flares and teaches the patient that the drug does not work. Where urate-lowering therapy is being started, it can be started during or after a flare, with anti-inflammatory prophylaxis covering the first months.
The second is reading a serum urate taken during an acute attack. Urate frequently falls during a flare and a normal result at that moment does not exclude gout — nor does it indicate that treatment is at target. The level to act on is one taken when the patient is between attacks, and treatment is titrated to a target, conventionally below 360 µmol/L, or lower where there are tophi.
The corollary is that the target is a number, not a symptom. A patient who has had no attacks for a year on a dose that never reached target has not been treated successfully; they have been lucky, and the tophus burden is still accumulating. Check the urate, not just the history, and escalate the dose until the target is met.
- Continue urate-lowering therapy through an acute flare rather than stopping and restarting it
- Do not exclude gout on a normal serum urate taken during an attack; recheck between attacks
- Titrate to a serum urate target rather than to the absence of symptoms
- Cover the first months of urate-lowering therapy with anti-inflammatory prophylaxis
- Recheck the urate before concluding that a patient with no recent attacks is adequately treated
Why it matters
Most treatment failure in gout is a dose that was never escalated to target in a patient who stopped having attacks.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for rheumatology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free