All About Gout: 10 New Ways to Beat an Old Foe

August 15, 2013

Becoming familiar with recent developments in managing “the king of diseases and the disease of kings” may help.

Gout-“the king of diseases and the disease of kings” in olden days-has risen in frequency in newer times. This recent “flare” probably is the result of increasing risk factors, such as longer life expectancy and lifestyle and diet changes. Now more than 3 million persons in the United States have gout, and it can affect anyone, not just kings.

Updated guidelines have emerged in recent years. Becoming familiar with new developments in gout management may help you beat this old foe:

1. Currently, about 70% of patients with gout are treated exclusively in the primary care setting, and as the prevalence continues to grow, the chances of seeing patients in your practice continue to grow accordingly.

2. Monosodium urate crystals should be identified for a definite diagnosis of gout. If that is not possible, diagnosis may be supported by classic clinical features (eg, podagra, tophi, rapid response to colchicine) or characteristic imaging findings or both.

3. Xanthine oxidase inhibitor therapy with allopurinol or febuxostat is recommended as the first-line pharmacological urate-lowering therapy (ULT) approach in gout.

4. An acute gouty arthritis attack should be managed with pharmacological therapy, initiated within 24 hours of onset.

5.Patient education on diet, lifestyle, treatment objectives, and management of comorbidities is recommended as a core therapeutic measure.

6. Gout does not develop in all patients who have hyperuricemia, and patients who experience a gout attack are not necessarily found to have hyperuricemia.

7. Most studies have used the generic Health Assessment Questionnaire Disability Index and Short Form 36 to measure health-related quality of life (HRQOL) in gout. There is a need for a cohort study in primary care to determine which factors predict changes in HRQOL over time and help identify those at risk for deterioration and better target them for treatment.

8. Hyperuricemia results from overproduction and underexcretion of uric acid, which leads to signs and symptoms of gout in only one-third of persons with hyperuricemia. Hyperuricemia can have numerous causes other than dietary indiscretion, including hereditary enzymatic defects and vigorous muscle exertion causing excessive turnover of adenosine triphosphate. Underexcretion of uric acid may be a consequence of genetic disorders, diminished renal function, or medications.

9. A misconception is that gout does not occur in patients with rheumatoid arthritis (RA). In a longitudinal study, the 25-year cumulative incidence of gout diagnosed by clinical criteria in persons with RA was 5.3%. The rate of gout occurrence was lower than that in the general population, but the risk factors-male sex, obesity, and older age-were similar.

10.Complacency is a recurring concern in gout management. The disease is one of the most painful and destructive afflictions of human joints, but many patients and physicians consider it a minor inconvenience or a nuisance. However, gout is a chronic, progressive disease that deserves your and your patients’ full attention

In a recent national survey of primary care physicians, only half reported optimal treatment practices for the management of acute gout and  fewer than 20% for intercritical or tophaceous gout, suggesting that care deficiencies are common.