Strategies for improving on ‘crummy’ gout management
SAN DIEGO — Prolonged adherence to urate-lowering therapies is critical for patients to manage gout, yet only a fraction of patients receive the appropriate therapy, according to a presentation at the 2019 Congress of Clinical Rheumatology West.
“We do an absolutely crummy job of managing this disease,” N. Lawrence Edwards, MD, professor of medicine in the Division of Clinical Immunology at the University of Florida in Gainesville, told attendees. He suggested that there should be no excuse for this state of affairs. “There are many urate lowering therapies, and they work.”
Of the 9 million Americans with gout, just 1.1 million are adequately treated with the appropriate therapies, according to Edwards. His talk zeroed in on four basic concepts for improving this situation.
The first concept is to help patients understand that gout is purely a disease of urate burden. The stages are asymptomatic hyperuricemia, acute and intermittent gouty symptoms, and chronic tophaceous, or advanced, gout.
Edwards stressed, however, that as the symptoms flare and recede, urate is continuously increasing in the body. Patients perceive the flares and may believe that the condition is sporadic in nature. “The first lesson we need to communicate to our patients is that this not a disease that comes and goes, even though they may feel that way,” he said. “We now know that tophi exist even at the asymptomatic phase. The disease is getting worse all the time unless you are taking urate lowering therapies.”
The next basic concept pertains to the difference between hyperuricemia and gout itself. “The message is simple,” Edward said. “The higher the concentration of uric acid, the more the crystals precipitate out.”
Edwards next addressed the extent to which diet and exercise can slow this progression. This was the third basic concept of the talk.
“Can diet and exercise cure gout?” he said. “Short answer: No.”
Edwards acknowledged that overconsumption of certain foods may trigger flares, and that higher BMI can be associated with increased gout incidence, but that these are not hard and fast rules. “Is this really a self-inflicted disease?” he said. “Spoiler alert: It’s genetic. Diet accounts for only about 1% of uric acid variability.”
These distinctions are important because many patients believe that gout is a disease of the obese or “over-imbibers,” according to Edwards. This misinformation, and the associated stigmas, then, can impact the doctor-patient relationship in the clinic. “The more we talk about diet, the less they listen about the drugs that will stop the progress of this disease,” he said.
Regarding the fourth basic concept, Edwards highlighted differences between controlling acute flares and reducing urate burden. Flares can be treated using NSAIDS, colchicine or glucocorticoids, while allopurinol should be the mainstay of urate lowering therapy.
Other drugs in the urate-lowering armamentarium include febuxostat (Uloric, Takeda), probenecid (Probalan, Mylan Pharmaceuticals), lesinurad (Zurampic, Ironwood), and pegloticase (Krystexxa, Horizon).
Regardless of the drug, however, Edwards said both clinicians and patients can expect pushback from insurance carriers and other health care providers for one simple reason: “Urate lowering therapy is lifelong,” he said. Insurance carriers may be loath to cover the drug indefinitely, and other physicians may be alarmed at the dosing and duration of these drugs, particularly allopurinol. But Edwards encouraged rheumatologists to hold fast. “When you lower the serum urate level and reach the target, the faster the urate burden and the symptoms will be eliminated.” —Rob Volansky
Edwards NL. What’s New in Gout 2019? Presented at: Congress of Clinical Rheumatology West. Sept. 26-29, 2019; San Diego.
Disclosure: Edwards reports consulting for Ironwood Pharmaceuticals and Horizon Pharmaceuticals.