Ppx

• About
• Indications
• When to Stop
• References

About

Ppx is short for prophylaxis and, in the context of GoutHelper, is a tool to determine whether a patient should be on prophylaxis against gout flares. Prophylaxis is generally used in patients who are starting ULT. The rationale for this is that ULT can actually increase the risk of gout flares in the short-term, so prophylaxis is used to prevent this. It does not need to be continued indefinitely.

Indications

Anyone who is starting ULT has a guideline-based indication for prophylaxis per the 2020 ACR guidelines.

The guidelines are not as clear about patients who are already on ULT but who need to have their ULT titrated because they are having flares and/or are hyperuricemic. GoutHelper defaults to recommending prophylaxis in these instances, but this is not addressed in the guidelines or really in the scientific literature. We believe that, from the patient's perspective, fewer flares is better than more flares. In this context, prophylaxis is very optional.

If the patient is not on ULT, there is no role for prophylaxis. Prophylaxis of gout flares without ULT is misguided.

When to Stop

Prophylaxis should be continued until the uric acid has been at goal for at least 3-6 months. This is typically done by checking the uric acid on an every 1-2-3 month basis while ULT is being titrated. Some individuals who have gouty tophi, which are essentially dense deposits of monosodium urate, may need to be on prophylaxis for longer. This is because the tophi can take a long time to dissolve, and the dissolution of tophi is associated with a risk of flares.

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.