title: Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 3: Treatment.
abstract: The treatment of gout is based on several principles. Symptom control and termination of the inflammatory process are important early goals, whereas the urate level should be lowered in the long term to prevent further gout attacks and complications. The non-pharmacological approach is based on individually informing the patient on dietary measures and changes of life style. Besides physical measures, such as cold applications on the affected joint, various medications are available for treatment of an acute gout attack. The choice of drug depends on the individual risk profile. If non-steroidal anti-inflammatory drugs (NSAID) and coxibs are chosen it should be taken into account that the use is restricted in patients with renal insufficiency. Moreover, these drugs may have gastrointestinal side effects and are associated with increased cardiovascular morbidity and mortality. Colchicine has gastrointestinal side effects at high dosages but can also be used for differential diagnostics if there is a quick response to treatment. Steroids are an effective alternative and can be given orally or parenterally in patients with dysphagia. Moreover, steroids can be used in cases of renal insufficiency. After symptoms of the acute attack have subsided, urate lowering therapy should be initiated to prevent further attacks. Low-dose urate lowering therapy can be started during an acute gout attack when acute therapy is initiated. Allopurinol is still the medication of choice but its use is restricted in patients with renal insufficiency. A rare but serious side effect is allopurinol hypersensitivity syndrome. Febuxostat can be an alternative in patients who do not tolerate allopurinol. In February 2016, lesinurad, an URAT-1 and OAT-4 inhibitor, was approved in combination with allopurinol or febuxostat. Data on the effectiveness and safety of synthetic uricases and biologicals are still sparse for elderly patients. These substances are reserved for severe cases of gout.
authors.affiliation: Klinik für Allgemeine Innere Medizin und Geriatrie, Krankenhaus der Barmherzigen Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Germany. steffen.schlee@barmherzige-regensburg.de.
authors.forename: S
authors.initials: S
authors.lastname: Schlee
authors.affiliation: Lehrstuhl für Altersmedizin, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
authors.forename: L C
authors.initials: LC
authors.lastname: Bollheimer
authors.affiliation: Institut für Klinische Chemie, Laboratoriumsmedizin und Transfusionsmedizin, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Bertsch
authors.affiliation: Klinik für Allgemeine Innere Medizin und Geriatrie, Krankenhaus der Barmherzigen Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Germany.|Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, 90408, Koberger Straße 60, Nürnberg, Germany.
authors.forename: C C
authors.initials: CC
authors.lastname: Sieber
authors.affiliation: Klinik für Rheumatologie, Klinische Immunologie und Physikalische Therapie, Zentrum für Akutdiagnostik, Katholisches Klinikum Mainz, An der Goldgrube 11, 55131, Mainz, Germany.
authors.forename: P
authors.initials: P
authors.lastname: Härle
mesh_terms: D000368:Aged; D001168:Arthritis; D002118:Calcium; D002131:Calcium Pyrophosphate; D006073:Gout / Q000188:drug therapy; D006074:Gout Suppressants / Q000627:therapeutic use; D006801:Humans; D014527:Uric Acid
chemical_list: D006074:Gout Suppressants; D014527:Uric Acid; D002118:Calcium; D002131:Calcium Pyrophosphate
keywords: Acute gout flare; Colchicine prophylaxis; Geriatric patients; Parkinson disease; Urate-lowering therapy