PpxAid

• About
• Options
• Considerations
• References

About

PpxAids are a decision aid tool that determine the optimal choice of prophylaxis against gout flares for a given patient who is starting urate-lowering therapy (ULT). For advice on whether or not a patient needs prophylaxis, use a Ppx.

Options

Typically, prophylaxis is done with the same medications that are used for treatment of gout flares, just at lower doses. The most common options are: NSAIDs or colchicine, and less commonly prednisone.

Considerations

• NSAIDs are cheap, avilable over-the-counter, and generally well-tolerated. However, they really shouldn't be used for extended durations in patients who have cardiovascular diseases or any of a relatively long and hard-to-remember list of relative contraindications. These include anticoagulation, inflammatory bowel disease, chronic kidney disease, history of peptic ulcers or gastroinestinal bleeding, among many others.

• Colchicine should be cheap, but in the US it's not and is prescription only. In other countries it is cheap and readily available. It is generally well-tolerated. However, it can cause diarrhea and other gastrointestinal symptoms. It also has a long list of drug interactions, some of which are serious. It is also contraindicated in patients with severe renal impairment.

• Prednisone is sort of last resort, but is definitely reasonable. It's safe and cheap, but it's a steroid and has all the side effects that come with that. It can raise blood sugar, cause weight gain, and increase the risk of infections. It can also cause mood changes and insomnia. It's also not a great choice for patients with diabetes, but winds up being used in this circumstance not uncommonly due to lack of other options.

References

1. FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM, Gelber AC, Harrold LR, Khanna D, King C, Levy G, Libbey C, Mount D, Pillinger MH, Rosenthal A, Singh JA, Sims JE, Smith BJ, Wenger NS, Bae SS, Danve A, Khanna PP, Kim SC, Lenert A, Poon S, Qasim A, Sehra ST, Sharma TSK, Toprover M, Turgunbaev M, Zeng L, Zhang MA, Turner AS, Neogi T. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res (Hoboken). 2020 Jun;72(6):744-760. doi: 10.1002/acr.24180. Epub 2020 May 11. Erratum in: Arthritis Care Res (Hoboken). 2020 Aug;72(8):1187. Erratum in: Arthritis Care Res (Hoboken). 2021 Mar;73(3):458. PMID: 32391934.