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Prevention of recurrent gout: Pharmacologic urate-lowering therapy and treatment of tophi

Michael A Becker, MD
Section Editor
H Ralph Schumacher, MD
Deputy Editor
Paul L Romain, MD


Gout is monosodium urate crystal deposition disease; in the absence of urate saturation of extracellular fluids (reflected by hyperuricemia: serum urate levels >6.8 mg/dL [405 micromol/L]) and of urate crystal deposition and inflammatory responses to crystal deposition, the symptoms and signs of gout do not occur. In addition, there is no evidence that serum urate reduction to levels that remain above the limit of solubility carries with it clinical benefits equivalent to those achievable at sub-saturating levels. Thus, gout can be regarded as a “threshold” disease in which the long-term goal of therapy to prevent recurrent gout and reverse prior signs of the disease is to achieve and maintain sub-saturating serum urate concentrations.

Management for the prevention of recurrent episodes of acute gout and damage to joints and other tissues from urate crystal deposition includes drug therapy as well as lifestyle modification and other strategies for risk reduction. Long-term success in maintaining sub-saturating urate levels is attended by clinical benefits that include cessation of acute gout flares, resolution of tophi, and improvement in patient physical function and health-related quality of life. However, resolution of the urate crystal burden may require many months to several years to attain, even after sub-saturating urate levels are achieved either by lifestyle modifications (risk reduction) and/or with oral urate-lowering agents. During this period of crystal dissolution, a risk for acute flare remains and is the primary basis for gout flare prophylaxis with antiinflammatory agents.

The prevention of recurrent gout and of disease progression by use of urate-lowering drugs and the treatment of tophi will be reviewed here, as will antiinflammatory prophylaxis of acute gouty arthritis during initiation of antihyperuricemic therapy. The prevention of recurrent gout and disease progression by use of nonpharmacologic lifestyle modifications for urate lowering and by risk reduction involving drug choices for management of comorbid diseases (eg, hypertension), the clinical manifestations and diagnosis of gout, the treatment of episodes of acute gouty arthritis, and issues related to asymptomatic hyperuricemia are discussed separately. (See "Prevention of recurrent gout: Lifestyle modification and other strategies for risk reduction" and "Clinical manifestations and diagnosis of gout" and "Treatment of acute gout" and "Asymptomatic hyperuricemia".)


In most patients with gouty arthritis, the disease can be successfully managed by achieving and maintaining a sub-saturating target serum urate level with lifestyle modification/risk reduction strategies combined, as is often necessary, with pharmacologic therapy. Pharmacologic urate-lowering measures are usually required in patients with tophaceous gout, although, in a few patients with complications due to tophaceous disease, surgical intervention may be an adjunct to medical management. Treatment may be more challenging in patients with compromised renal function and large tophaceous deposits.

Upon resolution of an acute gouty attack, the patient is said to have entered an intercritical (between attacks) period (see "Clinical manifestations and diagnosis of gout", section on 'Intercritical gout and recurrent gouty arthritis'); during this period, the following preventive issues should be addressed:


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