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Pharmacologic Management of Gout in Patients with Cardiovascular Disease and Heart Failure

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Abstract

Gout is the most common inflammatory arthritis and is often comorbid with cardiovascular disease (CVD). Hyperuricemia and gout are also independent risk factors for cardiovascular events, worsening heart failure (HF), and death. The recommended treatment modalities for gout have important implications for patients with CVD because of varying degrees of cardiovascular and HF benefit and risk. Therefore, it is critical to both manage hyperuricemia with urate-lowering therapy (ULT) and treat acute gout flares while minimizing the risk of adverse cardiovascular events. In this review, the evidence for the safety of pharmacologic treatment of acute and chronic gout in patients with CVD and/or HF is reviewed. In patients with CVD or HF who present with an acute gout flare, colchicine is considered safe and potentially reduces the risk of myocardial infarction. If patients cannot tolerate colchicine, short durations of low-dose glucocorticoids are efficacious and may be safe. Nonsteroidal anti-inflammatory drugs should be avoided in patients with CVD or HF. The use of canakinumab and anakinra for acute gout flares is limited by the high cost, risk of serious infection, and relatively modest clinical benefit. For long-term ULT, allopurinol, and alternatively probenecid, should be considered first-line treatments in patients with CVD or HF given their safety and potential for reducing cardiovascular outcomes. An increased risk of cardiovascular death and HF hospitalization limit the use of febuxostat and pegloticase as ULT in this population. Ultimately, the selection of agents used for acute gout management and long-term ULT should be individualized according to patient and agent cardiovascular risk factors.

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Authors and Affiliations

  1. Department of Pharmacy, MedStar Union Memorial Hospital, Baltimore, MD, USA

    Mallory T. Mouradjian

  2. Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA

    Michael E. Plazak

  3. Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, 20 North Pine Street, Pharmacy Hall Room S402, Baltimore, MD, USA

    Stormi E. Gale, Zachary R. Noel, Kristin Watson & Sandeep Devabhakthuni

  4. ATRIUM Cardiology Collaborative, University of Maryland School of Pharmacy, Baltimore, MD, USA

    Stormi E. Gale, Zachary R. Noel, Kristin Watson & Sandeep Devabhakthuni

Authors
  1. Mallory T. Mouradjian
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  2. Michael E. Plazak
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  3. Stormi E. Gale
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  4. Zachary R. Noel
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  5. Kristin Watson
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  6. Sandeep Devabhakthuni
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Corresponding author

Correspondence to Sandeep Devabhakthuni.

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No external funding was used in the preparation of this manuscript.

Conflict of interest

Mallory T. Mouradjian, Michael E. Plazak, Stormi E. Gale, Zachary R. Noel, Kristin Watson, and Sandeep Devabhakthuni have no potential conflicts of interest that might be relevant to the contents of this manuscript.

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Mouradjian, M.T., Plazak, M.E., Gale, S.E. et al. Pharmacologic Management of Gout in Patients with Cardiovascular Disease and Heart Failure. Am J Cardiovasc Drugs 20, 431–445 (2020). https://doi.org/10.1007/s40256-020-00400-6

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