Acute gout Oral colchicine given in doses of 0.5 mg twice or 3 times daily is the treatment of first choice in acute gout. It works by inhibiting microtubule assembly in neutrophils. The most common adverse effects are nausea, vomiting and diarrhoea. Oral NSAIDs are also effective but are used less commonly since many patients affected by acute gout have coexisting cardiovascular, cerebrovascular or chronic kidney disease. Oral prednisolone (15-20 mg daily) or intramuscular methylprednisolone (80-120 mg daily) for 2-3 days are highly effective and are a good choice in elderly patients where there is an increased risk of toxicity with colchicine and NSAID . The IL-1b inhibitor canakinumab is effective but extremely expensive and so seldom given. Local ice packs can also be used for symptomatic relief. Prophylaxis for chronic gout Patients who have had a single attack of gout do not necessarily need to be given urate-lowering therapy, but individuals who have more than one acute attack within 12 months and those with complications such as tophi or erosions should be offered it . Allopurinol is the drug of first choice. It inhibits xanthine oxidase, which reduces the conversion of hypoxanthine and xanthine to uric acid. The recommended staing dose is 100 mg daily, or 50 mg in older patients and in renal impairment. The dose of allopurinol should be increased by 100 mg every 4 weeks (50 mg in the elderly and those with renal impairment) until the target uric acid level is achieved, side-effects occur or the maximum recommended dose is reached (900 mg/day). Febuxostat also inhibits xanthine oxidase. It is typically used in patients with an inadequate response to allopurinol, and when allopurinol is contraindicated or causes adverse effects. Febuxostat undergoes hepatic metabolism and no dose adjustment is required for renal impairment. It is more effective than allopurinol but commonly provokes acute attacks when therapy is initiated. The usual staing dose is 80 mg daily, increasing to 120 mg daily in patients with an inadequate response. Uricosuric drugs, such as probenecid, sulfinpyrazone and benzbromarone, lower urate levels but are seldom used in routine clinical practice. They are contraindicated in over-producers and those with renal impairment or urolithiasis and require patients to maintain a high fluid intake to avoid uric acid crystallisation in the renal tubules. Pegloticase is a biological treatment in which the enzyme uricase (oxidises uric acid to 5-hydroxyisourate, which is then conveed to allantoin) has been conjugated to monomethoxypolyethylene glycol. It is indicated for the treatment of tophaceous gout resistant to standard therapy and is administered as an intravenous infusion every 2 weeks for up to 6 months. It is highly effective at controlling hyperuricaemia and can cause regression of tophi. Lifestyle measures are equally impoant as drug therapy in the treatment of gout. Patients should be advised to lose weight where appropriate and to reduce excessive alcohol intake, especially beer. Ref - Davidsons 23e p1015-1016