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We use medications to reduce the inflammation during an acute attack. These include anti-inflammatories, corticosteroid and colchicine.
There are many anti-inflammatories on the market; some are over the counter (such as Nurofen, Brufen, Voltaren) and the others require prescription. You must let your doctor know if you are already taking an over the counter formulation, otherwise you might be taking two anti-inflammatories at the same time and end up having nasty complications.
Corticosteroid is a compound that is made from our adrenal glands. We need corticosteroid to survive. When our body goes through stress, such as an infection or injury, our adrenal glands pump out a large amount of corticosteroid to increase the metabolism and to modulate the inflammatory reaction so that it does not get out of control and result in damage to our body tissue. You can think of it as an anti-inflammatory which works in a different pathway, with completely different side effect profile. Corticosteroid can given as tablets, or even as an injection into the inflamed joint.
Colchicine is a medication derived from a plant. If used very early during an attack, it maybe possible to abort a full blown attack. Early clinical study used high doses to treat an acute attack (two tablets every two hours) but it is often associated with significant side effect including nausea, vomiting, diarrhea, and in some patients, dehydration and multi-organ failure. Subsequent studies showed that smaller doses are equally effective (two to three tablets a day) and have a much lower chance of such side effects. Some formulations of colchicine have confusing names such as Lengout or Colgout, which can be easily confused with Progout, a formulation of allopurinol to lower serum uric acid and is used in a different manner.
All the above medications do not lower the uric acid level in the blood. They are used to treat an acute attack of gout and are also used during the initiation of uric acid lowering therapy to prevent an acute flare up.
The definitive treatment for gout is to reduce the uric acid level in the blood.
Dietary modification can be very helpful in early disease but if you have had gout for a long time, or if your uric acid level is significantly elevated, dietary modification alone is not enough. Nevertheless, it is useful to seek advice from a dietitian.
The most commonly used medication to lower uric acid is allopurinol (Progout, Zyloprim, Allosig, Allohexal). It drops the blood uric acid level very rapidly and this creates a gradient for the uric acid in our joints to move back into the circulation. It is believed that this movement of uric acid results in a flare up of gout, which is a phenomenon we see when we start allopurinol treatment. It is therefore very important that allopurinol is started at a reduced dose, together with a tablet such as anti-inflammatory, colchicine, or even low dose corticosteroid to prevent the flare up of gout during allopurinol initiation and titration.
The dose of allopurinol is slowly increased very few weeks until a target level of <0.36mmol/L is achieved. The whole process may take up to three months to complete. The most important thing during this period is not to stop the allopurinol if you develop an acute attack, but to immediately notify your rheumatologist to give you extra treatment to settle the inflammation and to ‘ride out’ the acute attack.
One size does not fit all. Clinical studies have shown that a significant number of patients do not achieve adequate control with the ‘standard dose’ of allopurinol 300mg a day. If your uric acid level is persistently elevated despite taking the allopurinol, you should see your rheumatologist for further dose escalation, or addition of another tablet to lower the uric acid.
Lastly, we must not forget gout is part of a ‘metabolic syndrome’ and is associated with cardiovascular events such as stroke or heart attack. Your rheumatologist will work with your general practitioner to address the other problems in this syndrome such as hypercholesterolaemia, diabetes and hypertension.
For more information on these medications, please refer to our patient information sheets page.