title: Treatment of chronic gouty arthritis: it is not just about urate-lowering therapy.
abstract: OBJECTIVE
  The management of gouty arthritis is focused on treating pain and inflammation associated with acute flares and preventing further acute flares and urate crystal deposition. A challenge associated with the successful management of gouty arthritis is an increased risk of acute flares during the first months after initiation of urate-lowering therapy (ULT). This increase in flare frequency can occur regardless of the choice of ULT and is linked to suboptimal patient adherence to ULT. Current treatment recommendations for the use of prophylaxis are limited. There are no definitive recommendations as to which agents should be used or for how long therapy is beneficial after starting ULT. This article aims to improve awareness of the importance of gouty arthritis flare prophylaxis when initiating ULT and to summarize current recommendations and clinical findings related to the efficacy and safety of currently available and investigational new therapies.
  
  
  METHODS
  This review discusses the pathophysiology of acute gouty arthritis flares during initiation of ULT and examines the literature on the use of anti-inflammatory prophylaxis for reduction of these flares.
  
  
  RESULTS
  It has recently become clear that, even when the patient is asymptomatic, chronic inflammation is often present in patients with chronic gouty arthritis. Chronic anti-inflammatory therapy should therefore be added to chronic ULT. Prophylaxis with colchicine as well as with nonsteroidal anti-inflammatory drugs (NSAIDs) during ULT initiation can reduce the incidence and severity of gouty arthritis flares substantially; however, safety concerns associated with colchicine and NSAIDs may limit their use.
  
  
  CONCLUSIONS
  When colchicine and NSAIDs are contraindicated or poorly tolerated, rilonacept and canakinumab, interleukin-1 inhibitors in trials, may prove to be useful alternatives for flare prevention. (Of note, although both inhibit the IL-1β pathway, rilonacept also binds to IL-1α and IL-1RA, in contrast to canakinumab, which binds selectively to IL-1β.).
authors.affiliation: Division of Rheumatology, Department of Medicine, UMDNJ/RWJMS, New Brunswick, NJ, USA. schlesna@umdnj.edu
authors.forename: Naomi
authors.initials: N
authors.lastname: Schlesinger
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D015210:Arthritis, Gouty / Q000097:blood / Q000188:drug therapy* / Q000503:physiopathology; D003078:Colchicine / Q000627:therapeutic use; D000075202:Contraindications; D057915:Drug Substitution; D006801:Humans; D033461:Hyperuricemia / Q000097:blood / Q000188:drug therapy*; D011993:Recombinant Fusion Proteins / Q000627:therapeutic use; D055502:Secondary Prevention; D012720:Severity of Illness Index; D014527:Uric Acid / Q000097:blood*; D014528:Uricosuric Agents / Q000627:therapeutic use*
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D011993:Recombinant Fusion Proteins; D014528:Uricosuric Agents; D014527:Uric Acid; C541220:canakinumab; C531377:rilonacept; D003078:Colchicine