Run the List – Gout: Acute and Long-Term Management

Episode Date: March 26, 2025
Host: Emily Gutowski (B), Walker Redd, Navin Kumar, Joyce Zhou, Blake Smith
Guest: Dr. Pillenger

Episode Overview

This episode of Run the List delves into the triggers and both acute and long-term management strategies for gout. Drawing from a pertinent clinical case, the discussion covers the underlying mechanisms that provoke gout flares, decision-making in acute treatment (including pharmaceutical choices and approach tailoring), long-term urate-lowering therapies, prophylactic measures during urate reduction, and practical communication pearls for patient care. Dr. Pillenger provides expert insights into current practice, evidence, and patient-centered counsel.

Key Discussion Points & Insights

1. Case Recap and Triggers for Gout Flares

[00:22–02:55]

• Recap: 55-year-old male with hypertension and hyperlipidemia, recurrent severe pain in big toe, typical gout features, and radiological evidence of punched-out erosion at the first MTP.
• Triggers:
  • Gout attacks can be triggered by both chronic and acute changes:
    • Time: Crystal deposition increases over years.
    • Fluctuations in urate levels—both increases and rapid drops.
    • Systemic stress or illness: "We often see people on the inpatient side develop an acute gout attack in the setting of an MI, in the setting of sepsis, in the setting of a procedure..." (A, 01:56)
    • Dehydration, metabolic stress, dietary triggers (alcohol, red meat, etc.) are reported, but the biologic basis is unpredictable.
  • Bottom line: “Ultimately the answer is we really don't know.” (A, 02:41)

2. Acute Management of Gout Flare

[02:55–08:38]

• Principle: Address acute inflammation—"The problem in front of us is inflammation." (A, 03:26)
• Main Treatment Options:
  • NSAIDs: Any can work, but avoid in renal disease; celecoxib and salsalate are safer alternatives. Use “higher doses—not like a headache dose.” (A, 04:22)
    • Indomethacin is classic but less used due to toxicity.
  • Glucocorticoids: Prednisone is standard (0.5 mg/kg); good for patients with renal disease or NSAID intolerance. Main caution: side effect profile, especially with longer courses.
  • Colchicine:
    • Ancient, “my favorite drug... first recorded in an Egyptian papyrus in the BC era.” (A, 05:25)
    • Best started early, low-dose regimens preferred for safety; main concern is toxicity at high doses, and interactions in renal disease and with certain meds.
    • Typical regimen: “two pills followed by one pill an hour later... then nothing for 24 hours.” (A, 06:06)
  • Steroid Injections: Useful if joint can be accessed and infection excluded.
  • IL-1 Inhibitors: Rarely needed; anakinra, canakinumab (the only one approved), and rilonacept can be used in refractory cases.
• Quote: “Pick the one that will do the least harm to the patient because they all will pretty much work.” (A, 03:43)

3. Transition to Long-Term Management

[08:38–19:02]

• Common Patient Misconception: Patients associate gout only with pain episodes; clinicians should clarify that “gout is a metabolic condition that you have all the time.” (A, 09:21)
• Who Needs Urate-Lowering Therapy?
  • Typically not after one isolated attack, unless high risk (e.g., very high urate, renal disease, ≥2 flares in a year).
• Lifestyle/Diet:
  • Diet modification (less meat/seafood, alcohol, fructose) can modestly reduce urate (~1 mg/dL)—“It isn’t about diet... best you can do with diet is drop your urate about a point.” (A, 11:03)
  • Emphasize healthy habits, but avoid blaming patients.
• Pharmacologic Approaches:
  • Xanthine Oxidase Inhibitors:
    • Allopurinol (first-line): Start low, titrate up; concern for rare hypersensitivity reactions, especially in patients with HLA-B*5801 allele (test in high-risk populations: Han Chinese, Koreans, Thai, African Americans).
    • Febuxostat: Similar efficacy; initial data suggested higher CV risk but subsequent studies less convincing—only avoid in patients with high CV risk if possible.
  • Uricosuric Agents:
    • Probenecid: Promotes renal urate excretion; rarely first-line, limited by potency and practical concerns (frequent dosing, hydration).
  • Pegloticase: Recombinant uricase “like Pacman, it just eats urate at a remarkable rate.” (A, 16:43) Reserved for severe, refractory, or tophaceous cases; “life changing” in right patients but expensive and immunogenic (needs methotrexate co-administration).
  • General Strategy: "Treat to target" approach—get serum urate below 6 mg/dL (the insolubility threshold is 6.8 mg/dL).

4. Addressing Flare Risk During Urate-Lowering Initiation

[19:08–23:16]

• Why Prophylaxis?: Paradoxically, reducing urate initially increases flare risk (crystals are sloughed off joints).
  • “So when we start any of these urate lowering drugs, we go through a period of, rather than decreased risk, increased risk for gout flares.” (A, 19:31)
  • Patients may wrongly blame new meds for worsening symptoms if not counseled properly.
• Options for Flare Prophylaxis:
  • Colchicine (preferred—safe at low dose, “one pill a day, if they break through... a pill twice a day.” A, 21:05)
  • NSAIDs (usually COX-2 selective if used; less preferred due to long-term toxicity)
  • Low-dose prednisone (not ideal for long term)
  • Slow uptitration of allopurinol is an alternate but less practical approach (risks patient nonadherence)
  • IL-1 inhibitors—reserved for special cases.
• Duration: Minimum 3 months, may extend up to 12 months or more depending on flare frequency and comorbidities.
• Other Pearls:
  • Colchicine has shown cardiovascular benefit in MI reduction in gout patients; may stay on longer with cardiac comorbidity.
  • Important to continually customize and educate: “sometimes using things like drawings and diagrams can be helpful for our patients as they're learning about their new diagnosis of gout.” (B, 23:37)

5. Closing Pearls & Philosophy

[23:16–23:52]

• Gout care is highly individualized, requires clear patient communication, and should emphasize the chronic metabolic nature of the disease, not just episodic flares.

Notable Quotes & Memorable Moments

| Timestamp | Speaker | Quote | |-----------|---------|-------| | 02:41 | A (Dr. Pillenger) | “Ultimately the answer is we really don't know.” (on precise triggers for gout attacks) | | 03:26 | A | "The problem in front of us is inflammation." | | 03:43 | A | “Pick the one that will do the least harm to the patient because they all will pretty much work.” | | 05:25 | A | “It’s my favorite drug in the... an extremely old drug, first recorded in an Egyptian papyrus in the BC era.” (on colchicine) | | 06:06 | A | “The dose for an acute flare is two pills followed by one pill an hour later... and nothing for 24 hours.” (on colchicine dosing) | | 09:21 | A | “Gout is a metabolic condition that you have all the time.” | | 11:03 | A | “It isn’t about diet... best you can do with diet is drop your urate about a point.” | | 16:43 | A | “It’s kind of like Pacman, it just eats urate at a remarkable rate.” (on pegloticase) | | 19:31 | A | “When we start any of these urate lowering drugs, we go through a period of, rather than decreased risk, increased risk for gout flares.” | | 23:37 | B (Dr. Gutowski) | "Sometimes using things like drawings and diagrams can be helpful for our patients as they're learning about their new diagnosis of gout." |

Timestamps for Key Segments

• Gout Triggers & Case Recap: 00:22 – 02:55
• Acute Management of Flares: 02:55 – 08:38
• Initiating Long-term Management & Urate-lowering Therapy: 08:38 – 19:08
• Prophylaxis During Urate Lowering: 19:08 – 23:16
• Patient Communication & Closing Pearls: 23:16 – 23:52

Summary Table: Medications in Acute and Long-Term Gout Management

| Medication/Class | Acute or Chronic | Key Points | |----------------------------|------------------|--------------------------------------------------------------| | NSAIDs (e.g., ibuprofen) | Acute | Avoid in renal disease; use high doses; COX-2 preferred for GI risk | | Prednisone | Acute | Great for renal or NSAID-intolerant patients; short term only | | Colchicine | Acute & Proph | Old, effective, dosed low for safety; best started early | | IL-1 inhibitors | Refractory Acute | Specialist use only; canakinumab only FDA-approved | | Allopurinol | Chronic | First-line urate-lowering; titrate; beware rash/HLA-B*5801 | | Febuxostat | Chronic | Alternative in intolerance; initial CV concerns likely minimal| | Probenecid | Chronic | Rarely first-line; uricosuric; practical concerns | | Pegloticase | Chronic, Severe | Biologic “Pacman”; for severe, refractory, or tophaceous gout |

Key Takeaways for Trainees

• Always address acute pain promptly; choose anti-inflammatory based on patient comorbidities.
• Educate patients that gout is chronic, not just episodic.
• Urate-lowering therapies are for frequent/recurrent or high-risk patients, with target urate <6 mg/dL.
• Initiate flare prophylaxis when starting urate-lowering therapy, with colchicine preferred for most.
• Monitor for and counsel about rare drug-related risks (e.g., allopurinol hypersensitivity).
• Patient education and individualized care plans—including visual aids—optimize long-term outcomes.

End of Summary