Gout treatment’s main adversary

4 minute read

Benefits of a treat-to-target strategy are hampered by poor adherence and a lack of knowledge about the condition.

New research backs a treat-to-target strategy for gout, but its benefits are overshadowed by the problem of poor patient adherence and a lack of understanding of the disease and how it should be managed, says a Dubbo rheumatologist. 

Professor Mark Arnold, head of Sydney University’s Clinical School of Medicine at the School of Rural Health, said patients were often only seen when their gout was in the chronic or acute stage where the focus was on treating, rather than also on preventing flare ups and attacks. 

“There is not a good understanding of how to manage gout in general, chronic gout and acute gout in particular,” he said.  

Professor Arnold’s comments followed research, published in The Lancet Rheumatology, that found achieving an average serum urate concentration of less than 6mg/dL over a six-month period was associated with subsequent absence of gout flares, a reduction in the number of gout flares, and resolution of tophi in people with gout during the second year of treatment. 

The paper conceded there has been debate between rheumatologists and the American College of Physicians (ACP) about the use of serum urate as a surrogate and the treat-to-target serum urate strategy in the management of gout. 

Use of serum urate as a treatment target and an outcome measure became controversial in view of the ACP’s 2017 clinical practice guidelines for gout, which advocated a treat-to-symptom approach to gout management as an alternative to the treat-to-target serum urate approach recommended by other professional bodies.

“We have shown in this study that serum urate is a valid surrogate for gout flares and tophi, and we hope that the highest level of evidence based on RCTs, such as that presented here, will enable recommendations to be aligned between rheumatology organisations and the ACP,” the researchers wrote in The Lancet Rheumatology article. 

Associate Professor Helen Keen, consultant rheumatologist at Royal Perth Hospital and faculty member at the University of Western Australia, said the results would probably not come as a great surprise to some clinicians. 

“[The findings] neither change our practice but indeed validate the way rheumatologists have been practising in recent years,” she said. 

The authors of the study analysed individual patient-level data from two randomised trials on urate-lowering therapies in people with gout conducted in Nottingham, UK, and New Zealand. Individuals who on average achieved a serum urate concentration less than 6 mg/dL (0·36 mmol/L) based on data at six, nine and 12 months-post-baselines were defined as serum urate responders. 

Serum urate non-responders were participants who had an average serum urate of at least 6 mg/dL based on data at six, nine and 12 months. They then compared the two groups according to clinical outcomes assessed between 12 and 24 months. They identified 343 serum urate responders and 245 serum urate non-responders.  

“Significantly fewer serum urate responders had a gout flare than did serum urate non-responders between 12 and 24 months (91 [27%] of 343 vs 156 [64%] of 245),” they found. 

Professor Arnold said there was still a lot of misunderstanding about gout in the community – especially that it was purely a “lifestyle” disease” related to diet and alcohol. He said patients often received mixed messages from friends and relatives about the role drugs like allopurinol had to play in keeping attacks at bay. 

“Patients are not taking gout seriously, they are often embarrassed because they hear people tell them ‘if you change your diet, you’ll fix your gout’, and there is a general resistance to taking medication,” he said. 

“It’s a metabolic disease that’s unique to the human metabolism,” he said. “It can be enormously demoralising.” 

He hoped more dialogue about the disease between GPs, other specialists, and hospital staff would ensure patients were better educated and motivated to manage their gout, rather than simply treating attacks and flare-ups. 

“We should be almost delighted to see people with gout because we’re almost always on a winner, provided they stick to the treatment plan,” he said. “This is a disease you don’t really need to suffer from.” 

The Lancet Rheumatology 2021, online 5 November 

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