Is there anything new in the scientific pipeline for those of us who suffer from chronic gout? I'm having more and more trouble finding a drug that works when the attack comes on.
The goals of treatment and management of gout are twofold: (1) end acute attacks and prevent recurrent attacks and (2) to correct the excess uric acid in the blood called hyperuricemia. Nonsteroidal antiinflammatory drugs (NSAIDs) work well for most patients to reduce the pain and inflammation of an acute attack. Once in a while, a steroid injection into the joint is needed for an especially acute attack. Allopurinol is a drug that can prevent or lessen future gout attacks by slowing the rate at which the body makes uric acid in cases of excess uric acid production. This is taken on a consistent basis, not just when an attack is coming on. Other medications can be used to lower uric acid levels in the blood by increasing the amount of uric acid passed in the urine. These pharmacologic agents must be taken on a continuous basis to maintain a lower concentration of uric acid in the blood. Once the acute attack has been relieved, the hyperuricemia may be treated, especially in the case of recurrent attacks of acute gouty arthritis or chronic gout. This requires lifelong management, and compliance is absolutely necessary. Dietary changes, weight loss, and moderation of alcohol intake are all important. Controlling the hyperuricemia is the key to preventing this disease from becoming chronic and disabling. Although these drugs can prevent and/or treat painful gouty attacks, they don't work for everyone and they often have nasty side effects. And many patients have other health problems (e.g., diabetes, hypertension, kidney disease) that make it impossible to take the current drugs for gout. So there's a call for safer, more effective therapy for gout. What's on the horizon right now? Well, the European Commission (like the U.S. Food and Drug Administration) has approved a new therapy called febuxostat. It lowers uric acid slowly enough to avoid flaring up the gout. It isn't processed by the kidney, so it's possible patients with kidney disease may be able to take it. But it is metabolized by the liver. Anyone with a liver problem or who abuses alcohol may not be able to take this drug. When all else fails, there is a rather expensive ($8,000 per dose), but effective enzyme treatment (pegylated uricase) that may be helpful for rescue therapy. Rescue therapy refers to the patient with extreme, uncontrolled, and very painful gout for whom nothing else has worked. Once the worst of the problem has been treated, the patient can be switched to something else (one of the more standard treatments available). Scientists continue to explore all avenues of possibility in seeking a way to prevent, treat, and/or manage gout. As new biologic agents are developed for other inflammatory conditions, these will be tried with patients who have gout. The hope is to find something that works quickly in order to offset the high cost of most new drugs.