Tophi and frequent gout flares are associated with impairments to quality of life, productivity, and increased healthcare resource use: Results from a cross-sectional survey

Determinants of Self-Management Behavior in Gout: A Scoping Review

OBJECTIVE

This study aimed to identify modifiable determinants of self-management behavior in patients with gout.

METHODS

Four databases (Medline, Embase, PsycINFO, and CINAHL) were searched using terms related to gout, self-management, and determinants of behavior as described in the Theoretical Domains Framework (TDF). Two reviewers independently selected relevant studies via screening of title/abstract and full text. Thematic synthesis was performed for qualitative data; quantitative data were summarized using cross-tabulation displaying the investigated associations of determinants with self-management behavior. The TDF facilitated identification and grouping of determinants.

RESULTS

From 2,087 unique articles found, 56 studies were included in this review, of which there were 27 qualitative and 29 quantitative studies. Eight themes were identified: knowledge and skills for self-management, acceptance of disease, beliefs about necessity of self-management to improve gout-related health, resistance and reluctance for medication adherence and dietary alteration/changes, negative emotions influencing self-management, social support and interactions, environmental context, and self-regulation of behavior. Quantitative determinants associated with self-management behavior, predominantly medication adherence, were mapped to 12 of the 14 domains of the TDF. No determinants regarding skills and goals have been identified in quantitative research.

CONCLUSION

Intervention targets for self-management behavior in patients with gout mainly included determinants related to knowledge, implicit and explicit beliefs and attitudes, the environmental context and resources, and (social) support and reinforcement.

Quality of life improvements and clinical assessments in kidney transplant recipients undergoing pegloticase treatment for uncontrolled gout: findings of the phase 4 PROTECT clinical trial

Introduction

Gout is 12-times more prevalent in kidney transplant (KT) recipients than in non-transplanted population. We report quality-of-life (QOL) and clinical assessment findings from the PROTECT trial examining pegloticase efficacy and safety in KT recipients with uncontrolled gout.

Methods

Patients with serum urate (SU) ≥7 mg/dL, oral urate-lowering therapy refractory/intolerant, and with one of the following were enrolled: ≥2 flares/year, unresolving tophi, or chronic gouty arthritis. Patients were ≥1 year post-transplant, with a graft eGFR ≥15 ml/min/1.73m2 and received stable immunosuppression. Pegloticase was administered for 24 weeks. QOL endpoints included the Health Assessment Questionnaire (HAQ; Disability Index [DI], Health, Pain) and Physician Global Assessment (PhGA) of Gout. Key clinical assessments included proportion of patients with resolution of ≥1 tophus and change from baseline in blood pressure (BP) at Week 24.

Results

Twenty KT recipients (85.0% male, age: 53.9±10.9 years, BMI: 30.6±7.2 kg/m2, eGFR: 45.8±11.9 ml/min/1.73 m2, time since kidney transplant: 14.6±6.9 years) were included. The primary endpoint was achieved with 89% of patients reaching and maintaining a SU of <6 mg/dL during Month 6. Meaningful improvements occurred over 24 weeks of treatment in all QOL measures (mean [95% CI] change from baseline: HAQ-DI: -0.3 [-0.6, 0.1], HAQ-Pain: -35.5 [-54.5, -16.5], HAQ-Health: -22.4 [-39.5, -5.2], PhGA: -2.4 [-3.7, -1.1]) and clinical assessments (≥1 tophus resolved: 3 of 7 with tophi at baseline [42.9%]; change from baseline in mean arterial BP: -6.8 [-12.5, -1.0] mmHg).

Conclusions

Given the high prevalence of uncontrolled gout in KT recipients, proper SU management is of particular importance. Additionally, intensive urate-lowering with pegloticase may have clinical and QOL benefits.

Analysis of the efficacy of multidisciplinary integration based on 3D reconstruction technology for the treatment of gout stone

OBJECTIVE

This study investigates the efficacy of multidisciplinary fusion therapy based on 3D reconstruction technology for the treatment of gouty stone by comparing the efficacy of multidisciplinary fusion therapy with pharmacologic therapy.

METHODS

This study is a cohort study.Patients who underwent gout stone surgery at the Affiliated Hospital of Qingdao University from November 2020 to November 2022 were included in this study, totaling 85 to form the MDT surgery group, and matched among gout stone patients in the outpatient clinic during the same period to form the medication group. Patients in the 2 groups were followed up for 6 months to compare baseline and follow-up data.

RESULTS

Both groups experienced a decrease in uric acid levels and an increase in SF-36 scores during follow-up. After adjusting for confounders, multifactorial logistic regression showed that the uric acid attainment rate of patients in the MDT surgery group was 4.011 times higher than that of the drug group (OR: 4.011, 95% CI: 1.595, 10.086, P = 0.003); the proportion of patients with an increase in SF-36 in the MDT surgery group was 4.976 times higher than that of the drug group (OR: 4.976, 95% CI: 2.243, 11.040, P < 0.001); the proportion of patients treated with high-dose medication in the MDT surgery group was 1.8% of that of patients in the drug group (OR: 0.018, 95% CI: 0.002, 0.148, P < 0.001); and the proportion of patients in the MDT surgery group who developed frequent gout was 2.8% of that in the drug group (OR: 0.028 95% CI: 0.003, 0.2398, P = 0.001). the proportion of patients in the MDT surgery group who developed abnormal liver function was 0.317 times higher than that in the drug group (OR: 0.317, 95% CI: 0.121, 0.831, P = 0.019).

CONCLUSION

The multidisciplinary integration of 3D reconstructive techniques for gout stone treatment resulted in an increase in uric acid compliance, a decrease in the frequency of gout and the appearance of liver impairment; and a greater benefit in terms of improvement in the quality of life of the patients after treatment.

Characteristics and Management of Uncontrolled Gout Prior to Pegloticase Therapy: A 2-year Claims Analysis

OBJECTIVE

Gout is a progressive form of arthritis that causes significant pain and disability. Patients with treatment-refractory (or uncontrolled) gout experience a higher prevalence and severity of comorbidities than those whose gout is controlled. Pegloticase is a recombinant PEGylated uricase indicated for the treatment of gout in patients refractory to conventional therapy. We evaluated the treatment journey of patients with chronic uncontrolled gout before initiation of pegloticase therapy.

METHODS

Using IQVIA's PharMetrics® Plus database, we conducted a retrospective observational analysis of adults with ≥ 1 pegloticase claim between April 1, 2011, and August 31, 2020. Demographics were assessed at baseline. Clinical outcomes, health care resource utilization (HCRU), and associated costs were compared over two 12-month periods (months 13-24 and 1-12) prior to the first pegloticase claim (index date).

RESULTS

The study included 408 patients. Prevalence of all gout-associated conditions increased between months 1-12 and 13-24 (P < 0.05 for all). The percentage of patients with tophi increased from 15.4% to 61.5%, the percentage with ≥ 1 flare increased from 49% to 84%, and mean number of flares per patient increased from 1.0 to 2.1 (P < 0.0001 for all). The frequency of all categories of HCRU except emergency department visits also increased (P < 0.0001 for all), as did gout-related healthcare utilization (P£0.005).

CONCLUSIONS

Patients with uncontrolled gout experienced an increase in the clinical burden of disease and HCRU in the 2 years before the initiation of pegloticase. Earlier patient identification and initiation of potentially effective therapy may help alleviate these burdens.

Gout Flare Burden in the United States: A Multiyear Cross-Sectional Survey Study

OBJECTIVE

The objective of this study was to assess the burden of gout flares and examine associated patient characteristics and outcomes in a sample of US adults.

METHODS

Data were collected via an online survey of US adults ≥18 years using a random stratified sampling framework. Participants with gout completed questions about treatments, serum urate (SU) levels, severity, satisfaction with control, and gout flares. All participants completed the Veterans RAND 12-Item Health Survey, the Generalized Anxiety Disorder 7-Item Scale, and the Patient Health Questionnaire 9-Item Scale. Data were summarized using descriptive statistics. Multivariable-adjusted logistic regression analyses examined factors predictive of reporting gout flares to a physician.

RESULTS

A total of 933 participants met the study criteria for having gout. Those with gout tended to be older (58.3 [SD 13.3] years vs 45.4 [SD 16.1] years; P < 0.001), male (76.3% vs 46.9%; P < 0.001), White (80.5% vs 76.8%; P = 0.01), and married or living with their partner (58.9% vs 52.8%; P < 0.001) compared with those without gout (n = 30,146). The total gout flare burden for those with gout was 6.6 gout flares per year. Nearly 72% of gout flares were either not reported to physicians or pretreated or prevented. Characteristics of those who were less likely to report gout flares included being younger, being less educated, having a lower Charlson Comorbidity Index score, not being diagnosed with gout by their doctor, and not taking a urate-lowering therapy.

CONCLUSION

This study confirmed that gout flares are common in US adults with gout and found that gout flares are underreported. Reliance on clinical documentation of physician-reported gout flares is insufficient to assess the true patient burden of gout.

Quality of life and clinical gout assessments during pegloticase with and without methotrexate co-therapy: MIRROR randomized controlled trial exploratory findings

Objectives

Pegloticase lowers serum urate (SU) but is limited by anti-drug antibodies. Methotrexate (MTX) co-administration increases urate-lowering response rate and decreases infusion reaction risk. This is of importance in uncontrolled gout patients who have few treatment options and highly impacted quality of life (QOL). Here, we report exploratory QOL/clinical endpoints of MIRROR RCT (NCT03994731).

Methods

Patients with uncontrolled gout (sUA ≥ 7 mg/dl, urate-lowering tehraoy (ULT) failure/intolerance, and ≥1 gout sign/symptom [≥1 tophus, ≥2 flares in past year, chronic gouty arthritis]) were administered pegloticase (biweekly 8 mg infusion; 52 weeks) with oral MTX (15 mg/week) or placebo co-therapy. Key exploratory outcomes included change from baseline (CFB) in Physician Global Assessment of Gout [PhGA, score: 0-10], CFB in tender/swollen joint counts [TJC/SJC, score: 0-68/0-66], and gout chronic response rate (GCR50, GCR70; 50%/70% reduction in ≥3 of TJC, SJC, HAQ-Health, HAQ-Pain). Least-square mean (±S.E.) CFB to week 52 was estimated using a mixed model for repeated measures.

Results

In total, 100 patients were randomized to pegloticase + MTX; 52 to pegloticase + PBO. At baseline, patients had poor overall health (HAQ-Health [MTX, PBO]: 44.9 ± 28.6, 39.1 ± 27.4; PhGA: 5.5 ± 2.1, 5.4 ± 2.2) and many affected joints (TJC: 5.4 ± 7.8, 6.7 ± 8.4; SJC: 8.3 ± 12.2, 11.0 ± 15.9). QOL progressively improved during treatment, with similar CFB at week 52 in MTX vs. PBO groups in PhGA (-4.2 ± 0.2 vs. -3.8 ± 0.3) and TJC/SJC (-6.1 ± 0.5 vs. -7.0 ± 0.8/-5.1 ± 0.4 vs. -6.0 ± 0.6). However, at week 52, more MTX patients met GCR50 (58.0% vs. 38.5%) and GCR70 (52.0% vs. 30.8%) criteria.

Conclusion

In the MIRROR RCT, pegloticase treatment with or without MTX co-therapy led to meaningful clinical/QOL improvements in uncontrolled gout patients. However, patients receiving MTX co-therapy had greater benefits because of a higher sustained SU-lowering rate (60.0% vs. 30.8% in the PBO group at week 52).

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT03994731.

Establishment and validation of predictive model of prostate cancer

Prostate cancer is a prevalent malignant disease among middle-aged and elderly men. Its prevention and detection are significant public health issues. We aimed to construct an interpretable model for predicting death risk in prostate cancer patients. We performed model development using the Cancer Genome Atlas and the Genotype-Tissue Expression databases. In comparison among models, the SVM model has the highest prediction performance among the eight models. The SHAP method, sorted by importance, reveals the top eight predictors of prostate cancer disease. This effective computer-aided approach can facilitate frontline clinicians in the diagnosis and management of patients with prostate cancer.

The causal association between immune cells and gout: A bidirectional two-sample Mendelian randomization study

Gout, a metabolic disorder, is increasingly being linked to immune cells. However, the causal relationships between these factors remain unclear. Our study aimed to elucidate the causal relationship between immune cells and gout. Our study used 2-sample Mendelian randomization (MR) to explore the causal relationship between immune cells and gout. It is noteworthy that we utilized 5 methods MR-Egger, weighted median, inverse variance weighted, weighted mode, and simple mode to ensure the reliability of the results. Comprehensive sensitivity analyses were performed to verify the robustness, heterogeneity, and horizontal pleiotropy of the results. After false discovery rate correction (PFDR <0.20), 3 immunophenotypes were identified: one in the B cell panel, one in the regulatory T cells panel, and another in the T lymphocytes, B lymphocytes, Natural Killer cells panel. Among them, 2 immunophenotypes (CD4-CD8-T cell absolute count and CD25 on IgD + CD24 + B cell) increased the risk of developing gout, whereas the other one immunophenotype (CD45RA + CD28- CD8 + T cell %T cell) decreased the risk of gout. Subsequently, we did not observe heterogeneity and horizontal pleiotropy stable in these data through comprehensive sensitivity analyses. Furthermore, we identified some positive results in reverse MR analysis, but after false discovery rate correction (PFDR <0.20), no significant results were detected. Our study revealed causal relationships between immune cells and gout, providing novel insights into the prevention and treatment of gout.

Risk of incident gout following exposure to recombinant zoster vaccine in US adults aged ≥50 years

OBJECTIVE

To assess whether recombinant zoster vaccine (RZV) is associated with an increased risk of new-onset gout among US adults aged ≥50 years.

METHODS

We conducted a real-world, retrospective safety study with a self-controlled risk interval (SCRI) design using administrative claims data. We included health plan members aged ≥50 years with RZV exposure, followed by incident gout within 60 days. Days 1-30 following RZV exposure were considered the risk window (RW), and days 31-60 were considered the control window (CW). We estimated the risk ratio (RR) of gout in the RW versus CW, using a conditional Poisson model. The primary analysis estimated the risk of incident gout following any RZV dose. Sensitivity analyses evaluated dose 1- and dose 2-specific risks, risk among patients compliant with recommended dose spacing of 60-183 days, adjustment for seasonality, and restriction to the pre-COVID-19 era (before December 1, 2019).

RESULTS

A total of 461,323 individuals received ≥1 RZV dose; we included 302 individuals (mean age 72.5 years; 66 % male) with evidence of new-onset gout within 60 days in SCRI analyses. A total of 153 (50.7 %) individuals had gout events in the RW and 149 (49.3 %) in the CW (RR 1.03; 95 % confidence interval 0.81, 1.29). All sensitivity analyses had consistent results, with no association of RZV with incident gout.

CONCLUSION

In a population of US adults aged ≥50 years, there was no statistically significant increase in the risk of gout during the 30 days immediately after RZV exposure, compared with a subsequent 30-day CW.

Patient Experience with Chronic Refractory Gout and Its Impact on Health-Related Quality of Life: Literature Review and Qualitative Analysis

INTRODUCTION

Patients with chronic refractory gout face a considerable burden of disease due to unexpected flares characterized by severe and debilitating pain, which can lead to chronic pain and joint damage. This study aimed to understand the symptoms and impacts of chronic refractory gout on health-related quality of life (HRQoL).

METHODS

A targeted literature review was conducted to identify and review key articles describing the symptoms and impacts of gout, and articles examining the psychometric performance of the Medical Outcomes Survey Short Form-36 (SF-36) and Health Assessment Questionnaire-Disability Index (HAQ-DI) in gout. Qualitative interviews were conducted with 20 participants with chronic refractory gout. The results were used to develop the conceptual model and determine the appropriateness of the SF-36 and HAQ-DI in evaluating HRQoL in this population.

RESULTS

Most frequently reported symptoms included bodily pain (n = 18, 90.0%), joint swelling (n = 18, 90.0%), joint tenderness (n = 18, 90.0%), and joint pain (n = 16, 80.0%). Most frequently reported impacts were difficulties climbing a flight (n = 20, 100.0%) or several flights of stairs (n = 20, 100.0%), climbing five steps (n = 19, 95.0%), completing chores (n = 19, 95.0%), and running errands and shopping (n = 19, 95.0%). All assessed items from SF-36 and HAQ-DI were reported by ≥ 25% (n = 5) of participants and mapped sufficiently to concepts elicited by participants.

CONCLUSIONS

Patients with chronic refractory gout report symptoms and impacts that are highly bothersome and burdensome to everyday life. Items included in the HAQ-DI and SF-36 mapped directly to these symptoms and impacts and are relevant to understand the burden of disease of chronic refractory gout.

Limb salvage and systemic management of gouty tophi: Case series

INTRODUCTION

Gout is a chronic disease characterized by deposition of monosodium urate crystals. Tophi develop in some individuals with untreated or uncontrolled gout, which leads to ulcerations, cosmetic problems, mechanical obstruction of joint movement, joint damage and musculoskeletal disability. Currently, the treatment of gouty tophi is controversial and challenging. Both surgical and internal medical treatments have limitations and require further exploration in clinical practice.

PATIENT CONCERNS

In Case 1, we treated a patient with severe infection of diabetic foot ulcers with concomitant multiple gouty tophi in the same limb. A systematic management strategy was formulated to close the wound and save the limb. The ulcers healed successfully after half a year. In Case 2, a giant gouty tophi located in the first metatarsophalangeal joint of the left foot was removed by surgical treatment and vancomycin-loaded bone cement implantation. In Case 3, we present a case of gouty tophi that was resolved by standardized systemic medical management.

DIAGNOSIS

Three patients were all diagnosed with gout accompanied by gouty deposition, although there were other different comorbidities.

INTERVENTIONS

In case 1, we used debridement to gradually remove gouty tophi. In case 2, the giant gouty tophi was removed by surgical operation. In case 3, the gouty tophi disappeared after standardized treatment with medicine, diet and lifestyle management.

OUTCOMES

Three patients underwent different treatment therapies to remove gouty tophi based on their specific conditions.

LESSONS

We explored effective interventions for tophi in gout by surgical or other interventions in combination with pharmacotherapy.

Social Listening in Gout: Impact of Proactive vs. Reactive Management on Self-Reported Emotional States

INTRODUCTION

This study aimed to characterize patient-reported outcomes from social media conversations in the gout community. The impact of management strategy differences on the community's emotional states was explored.

METHODS

We analyzed two social media sources using a variety of natural language processing techniques. We isolated conversations with a high probability of discussing disease management (score > 0.99). These conversations were stratified by management type: proactive or reactive. The polarity (positivity/negativity) of language and emotions conveyed in statements shared by community members was assessed by management type.

RESULTS

Among the statements related to management, reactive management (e.g., urgent care) was mentioned in 0.5% of statements, and proactive management (e.g., primary care) was mentioned in 0.6% of statements. Reactive management statements had a significantly larger proportion of negative words (59%) than did proactive management statements (44%); "fear" occurred more frequently with reactive statements, whereas "trust" predominated in proactive statements. Allopurinol was the most common medication in proactive management statements, whereas reactive management had significantly higher counts of prednisone/steroid mentions.

CONCLUSIONS

A unique aspect of examining gout-related social media conversations is the ability to better understand the intersection of clinical management and emotional impacts in the gout community. The effect of social media statements was significantly stratified by management type for gout community members, where proactive management statements were characterized by more positive language than reactive management statements. These results suggest that proactive disease management may result in more positive mental and emotional experiences in patients with gout.

Clinical characteristics and risk factors associated with bone erosion in patients with tophi

INTRODUCTION

If a large amount of urate crystals is deposited in a joint cavity for an extended period of time, bone erosion will occur and gradually cause skeletal muscle necrosis and joint deformity. The aim of this study was to describe the clinical characteristics and factors associated with bone erosion in gout patients with tophi.

METHODS

A total of 210 gout patients with tophi were enrolled and divided into a bone erosion group (n = 135) and a non-bone erosion group (n = 75). Digital radiography (DR) was performed to detect bone erosion in the elbow, wrist, knee, ankle joints, interphalangeal and metatarsophalangeal joints. The clinical characteristics were recorded and compared between the two groups. Multivariate logistic regression analysis was conducted to explore the factors associated with bone erosion.

RESULTS

Compared with the non-bone erosion group, the bone erosion group had an older age, longer disease duration of gout and tophi, higher level of serum creatinine (sCr), higher proportion of drinking history and ulceration, and a lower glomerular filtration rate (GFR). Univariate logistic regression analysis results showed that sex, age, body mass index (BMI), gout duration, tophi duration, GFR, white blood cell (WBC) count, sCr level, smoking history, drinking history, and presence of ulceration were associated with bone destruction. Multivariable logistic regression analysis results indicated that tophi duration, drinking history, ulceration and sCr were positively and independently related to bone erosion.

CONCLUSIONS

Tophi patients with bone erosion presented different clinical characteristics. Tophi duration, drinking history, ulceration and sCr were associated with bone erosion in gout patients with tophi.

Gout and incidence of 12 cardiovascular diseases: a case-control study including 152 663 individuals with gout and 709 981 matched controls

BACKGROUND

Gout, a common crystal arthropathy, is associated with increased risk of cardiovascular disease. We aimed to identify how this risk varies by individual cardiovascular disease across a broad spectrum of conditions.

METHODS

In this matched case-control study, we used linked primary and secondary electronic health records from the UK Clinical Practice Research Datalink to assemble a cohort of individuals with a first-time diagnosis of gout between Jan 1, 2000 and Dec 31, 2017, who were aged 80 years or younger at diagnosis, and free of cardiovascular diseases up to 12 months after diagnosis. The control cohort comprised up to five control individuals per patient with gout, matched on age, sex, socioeconomic status, geographical region, and calendar time, randomly selected among individuals free of gout at any time before and during the study period. The cohorts were followed up until June 30, 2019. We investigated the incidence of 12 cardiovascular diseases and used Cox proportional hazards models to examine differences in people with and without gout, overall and by subgroups of sex, age, socioeconomic status, and year of study inclusion. We further adjusted models for known cardiovascular risk factors (blood pressure, BMI, smoking status, cholesterol, type 2 diabetes, chronic kidney disease, and history of hypertension).

FINDINGS

We identified 152 663 individuals with gout (mean age 56·2 years [SD 13·3]; 120 324 [78·8%] men and 32 339 [21·2%] women) and 709 981 matched controls (mean age 56·5 years [13·2]; 561 002 [79·0%] men and 148 979 [21·0%] women). Of these individuals, 31 479 (20·6%) with gout and 106 520 (15·0%) without gout developed cardiovascular disease during a median follow-up of 6·5 years (IQR 3·1-10·5). Patients with gout had higher risk of cardiovascular diseases than matched controls (hazard ratio [HR] 1·58 [95% CI 1·52-1·63]). Excess risk of cardiovascular disease in gout was greater in women than men (women: HR 1·88 [1·75-2·02]; men: HR 1·49 [1·43-1·56]), and, among all age groups, was highest in younger individuals (HR in people aged <45 years: 2·22 [1·92-2·57]). Excess risk was observed across all 12 cardiovascular diseases investigated. Patients with gout had higher BMI than matched controls (mean difference 2·90 kg/m2 [95% CI 2·87-2·93]) and higher prevalence of chronic kidney disease, dyslipidaemia, history of hypertension, obesity, and type 2 diabetes. Adjusting for known cardiovascular risk factors attenuated but did not eliminate the excess risk of cardiovascular disease related to gout (adjusted HR 1·31 [1·27-1·36]).

INTERPRETATION

Patients with gout had an excess risk of developing a broad range of cardiovascular diseases that extend beyond atherosclerotic diseases and include heart failure, arrhythmias, valve disease, and thromboembolic diseases. Excess risk was highest in women and younger individuals. These findings suggest that strategies to reduce cardiovascular risk in patients with gout need to evolve and be implemented in clinical practice.

FUNDING

Research Foundation Flanders.

Time- and Concentration-Dependent Stimulation of Oxidative Stress in Chondrocytes by Intracellular Soluble Urate

BACKGROUND

Gout could result in irreversible bone erosion, and chondrocyte might be involved in the process. Increased soluble urate is the early stage of gout and is strongly oxidative.

OBJECTIVE

To explore the effect of intracellular urate on the oxidative status of chondrocytes.

METHODS

A chondrocyte model was used. Serial concentrations of exogenous urate were incubated with chondrocytes for increasing amounts of time. Reactive oxygen species (ROS), oxidant, and anti-oxidant molecules were measured with biochemical assays, rt-PCR, and western blot. A urate transport inhibitor and oxidative inhibitors were used to confirm the effect of exogenous urate.

RESULTS

All concentrations of exogenous urate stimulated the production of ROS in a time- and concentration-dependent manner, as well as oxidant molecules, including hydrogen peroxide (H2O2), nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, nitric oxide (NO) inducible nitric oxide synthase (iNOS), and these effects, could be inhibited by oxidant inhibitors. However, anti-oxidant molecules, including acidic leucine-rich nuclear phosphoprotein-32A (ANP32A), ataxia-telangiectasia mutated (ATM), heme oxygenase-1 (HO-1), and the transcription factor nuclear factor erythroid 2 (NF-E2)-related (Nrf2), was decreased by high concentrations of exogenous urate after prolonged incubation, but not by low to medium concentrations of exogenous urate. By inhibiting soluble urate trafficking, benzbromarone significantly suppressed the effect of urate stimulus on the oxidant and anti-oxidant molecules.

CONCLUSION

Intracellular soluble urate could regulate chondrocyte redox balance in a time and concentration-dependent manner, and would be a target for regulating and protecting chondrocyte function in the early gout stage.

The Relationship Between Psychosocial Behavior and the Quality of Life of Male Gout Patients in Southwest China: A Cross-Sectional Study Based on an Information-Motivation-Behavioral Skills Model

Purpose

Gout is more severe in men, leading to a poor quality of life. Previous studies did not sufficiently pay attention to the quality of life and related factors in gout patients in Southwest China. This study aimed to investigate the quality of life of men with gout in Southwest China and explore the relationship between psychosocial factors and health-related quality of life from the perspective of an information-motivation-behavioral skill model.

Patients and Methods

This was a cross-sectional study conducted in the West China Hospital of Sichuan University located in Southwest China. In total, 230 male patients with gout were enrolled. The health-related quality of life of patients was assessed using the gout impact scale. The gout knowledge questionnaire was used to assess patients' information. The positive psycap questionnaire was used to assess motivation. The gout patients' self-management assessment scale was used to assess behavioral skills. Multiple linear regression was used to identify the factors associated with the health-related quality of life of patients.

Results

The overall mean gout impact scale score was 52.7±15.3 (maximum possible = 100). Factors associated with the total gout impact scale score were tophi (β=0.138, P=0.050), pain (β=0.255, P<0.001), and resiliency (β=-0.282, P<0.001). In addition, demographic characteristics (educational level, smoking and marital status), clinical characteristics (tophi, pain, number of attacks over half a year, and number of affected joints) and psychosocial behavior variables (resiliency, hope, disease treatment management, diet management) were associated with several dimensions of the gout impact scale.

Conclusion

The health-related quality of life of male patients with gout in Southwest China was at a medium level. We found that demographic characteristics, clinical characteristics, and psychosocial factors were associated with health-related quality of life of patients with gout. These findings can be used as a reference to improve health-related quality of life of patients with gout.

Lifestyle factors predict gout outcomes: Results from the NOR-Gout longitudinal 2-year treat-to-target study

OBJECTIVE

Gout is associated with lifestyle, body mass index (BMI) and comorbidities, including dyslipidaemia. We studied how in actively treated patients, anthropometric measures and lipid levels changed over 2 years and whether they predicted gout outcomes.

METHODS

Patients with a recent gout flare and elevated serum urate (sUA) received gout education and treat-to-target urate-lowering therapy over 1 year. Anthropometric measures with BMI, waist circumference (WC) and waist-height ratio (WHR) as well as lipid levels were measured yearly over 2 years. We examined whether baseline anthropometric measures and lipid levels were related to flares and to achieving the sUA target.

RESULTS

At baseline, patients (n=211) were with mean age of 56.4 years and 95% were male. Over 2 years, anthropometric measures were largely unchanged while cholesterol and low-density lipoprotein cholesterol (LDL-C) were reduced at year 1. Anthropometric measures were associated with presence of tophi. Higher baseline WC (OR: 0.96 per cm, 95% CI: 0.93 to 0.99) decreased and high level of high-density lipoprotein cholesterol (OR: 5.1 per mmol/L, 95% CI: 1.2 to 22.1) increased the chance of sUA target achievement at year 2. High LDL-C (OR: 1.8 per mmol/L, 95% CI: 1.2 to 2.6) predicted the chance of having a gout flare during year 2.

CONCLUSION

In actively treated patients with gout, anthropometric measures were largely unchanged over 2 years and lipid levels were reduced. High WC and lipid levels predicted unfavourable gout outcomes after 2 years.

Course and predictors of work productivity in gout - results from the NOR-Gout longitudinal 2-year treat-to-target study

OBJECTIVES

In patients with gout there is a lack of longitudinal studies on the course of work productivity. We explored longitudinal changes in and predictors of work productivity over 2 years.

METHODS

Patients in the NOR-Gout observational study with a recent gout flare and serum urate (sUA) >360 µmol/l attended tight-control visits during escalating urate lowering therapy according to a treat-to-target strategy. From the Work Productivity and Activity Impairment (WPAI) questionnaire, scores for work productivity and activity impairment were assessed over 2 years together with the Beliefs about Medicines Questionnaire and a variety of demographic and clinical variables.

RESULTS

At baseline patients had a mean age of 56.4 years and 95% were males. WPAI scores at baseline were 5.0% work missed (absenteeism), 19.1% work impairment (presenteeism), 21.4% overall work impairment and 32.1% activity impairment. Work productivity and activity impairment improved during the first months, and remained stable at 1 and 2 years. Comorbidities were not cross-sectionally associated with WPAI scores at baseline, but predicted worse work impairment and activity impairment at year 1. The Beliefs about Medicines Questionnaire subscale with concerns about medicines at baseline independently predicted worse overall work impairment and worse activity impairment at year 1.

CONCLUSIONS

In patients with gout who were intensively treated to the sUA target, work productivity and activity impairment were largely unchanged and at 1 year predicted by comorbidities and patient concerns about medication.

Health-related quality of life by gout severity in women and men with gout in primary care: results from a questionnaire study in Western Sweden

OBJECTIVE

We aimed to compare health-related quality of life (HRQoL) by gout severity, overall and by sex.

METHOD

A questionnaire was sent to patients with gout (n = 1444) identified at 12 primary care centres in Western Sweden. The questionnaire asked about comorbidities, gout-specific aspects, and HRQoL, using the RAND 36-Item Health Survey. Responders were divided into 'mild', 'moderate', or 'severe' gout based on the number of self-reported flares (0, 1-2, ≥ 3) during the past 12 months.

RESULTS

Out of 1444 gout patients, 784 (54.3%) responded to the questionnaire. Among the respondents, 673 [560 (83.2%) men and 113 (16.8%) women] provided answers regarding the number of gout flares in the past year. Of these, 322 (47.8%), 218 (32.4%), and 133 (19.8%) were classified as having mild, moderate, and severe gout, respectively. Allopurinol use was more frequent in those with mild disease. In more severe gout, HRQoL was reduced compared to less severe gout [severe vs mild gout, mean values for physical component summary (PCS) score 39.5 vs 43.6, p = 0.002, and mental component summary (MCS) score 46.6 vs 51.1, p < 0.001]. When excluding those with a flare in the past month, the HRQoL was still worse in severe gout (vs mild), although differences were attenuated and not statistically significant for the PCS and for women.

CONCLUSION

Gout severity, defined as the number of flares during the past year, was associated with significant reductions in HRQoL.

Articular mobilization promotes improvement in functional and inflammatory parameters in a gouty arthritis model

OBJECTIVE

Gouty arthritis is characterized by painful inflammation due to the deposition of monosodium urate crystals in joint tissues. Despite available treatments, many patients experience ineffective management and adverse effects. This study evaluated a manual therapy protocol involving passive joint mobilization at the peak of inflammation in a gouty arthritis model using functional and inflammatory parameters.

METHODS

Twenty male Wistar rats, 12 weeks old, were divided into two groups (n=10 each): Gouty Arthritis and Control Groups, which were further subdivided into treated and untreated groups (n=5 each). The Gouty Arthritis Group received intraarticular knee injection of 50µL of monosodium urate crystals, while the Control Group received 50µL of phosphate buffered saline. The treatment involved a 9-minutes session of grade III joint mobilization (according to Maitland). Nociception, grip strength, and edema were evaluated before induction (EV0), 7 hours after assessment (EV1), immediately after treatment (EV2), and 1 hour after treatment (EV3). The animals were euthanized, and synovial fluid was collected to analyze leukocyte migration.

RESULTS

The model mimicked the signs of the Gouty Arthritis Group, with a decrease in the threshold of nociception and strength and an increase in edema and leukocyte count. The mobilization protocol significantly increased the nociceptive threshold and grip strength and reduced edema; however, it did not reverse the increase in leukocyte count.

CONCLUSION

Our results suggest that mobilization promotes analgesia and may modulate the inflammatory process owing to reduced edema and subtle attenuation of cell migration, which contributes to strength gain.

Health-related quality of life in gout, psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis, results from a cross-sectional survey in Western Sweden

OBJECTIVES

Inflammatory joint diseases (IJDs) substantially affect health-related quality of life (HRQoL). We aimed to compare HRQoL between patients with gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA), and ankylosing spondylitis (AS): (i) overall; (ii) stratified by sex; and (iii) between women and men with the same IJD diagnosis.

METHOD

A survey including the RAND36-Item Health Survey for assessing HRQoL was sent to patients with a diagnosis of gout, PsA, RA, or AS, registered at a rheumatology clinic or primary care centre during 2015-2017. HRQoL was compared across IJDs. Because of age differences between diagnoses, age-matched analyses were performed.

RESULTS

In total, 2896/5130 (56.5%) individuals responded to the questionnaire. Of these, 868 had gout, 699 PsA, 742 RA, and 587 AS. Physical component summary (PCS) scores were more affected than mental component summary (MCS) scores for all diagnoses (PCS range: 39.7-41.2; MCS range: 43.7-48.9). Patients with gout reported better PCS scores than patients with PsA, RA, and AS, who reported similar scores in age-matched analysis. MCS scores were close to normative values for the general population and similar across IJDs. When comparing women and men with respective IJDs, women reported worse PCS (range, all IJDs: 34.5-37.4 vs 37.5-42.5) and MCS (PsA: 44.0 vs 46.8; RA: 46.1 vs 48.7) scores.

CONCLUSION

We found that patients with gout reported better PCS scores than patients with other IJDs, for whom the results were similar. Women reported overall worse PCS and MCS scores than men.

Pegloticase efficacy and safety in kidney transplant recipients; results of the phase IV, open-label PROTECT clinical trial

INTRODUCTION

Kidney transplant (KT) recipients have a high prevalence and severity of gout. Pegloticase (pegylated recombinant uricase) rapidly metabolizes serum uric acid (sUA), and its efficacy is not impacted by kidney function.

METHODS

This open-label, Phase 4 trial (PROTECT NCT04087720) examined safety and efficacy of pegloticase in 20 participants with KT > 1 year prior to enrollment and with uncontrolled gout (sUA ≥7 mg/dL, intolerance/inefficacy to urate lowering therapy, and ≥1 of the following: tophi, chronic gouty arthritis, ≥2 flares in past year) and functioning KT (estimated glomerular filtration rate [eGFR] ≥15 mL/min/1.73 m2 ) on stable immunosuppression therapy.

RESULTS

The primary endpoint was sUA response during month 6 (sUA < 6 mg/dL for ≥80% of time). The study enrolled 20 participants (mean ± SD); age: 53.9 ± 10.9 years, time since KT: 14.7 ± 6.9 years, sUA: 9.4 ± 1.5 mg/dL, gout duration: 8.4 ± 11.6 years; all on ≥2 stable doses of immunosuppression agents. Pegloticase (8 mg intravenous every 2 weeks) in KT recipients with uncontrolled gout showed a high response rate of 89% (16/18 responders). Two participants discontinued treatment solely due to COVID-19 concerns prior to month 6 were not included in the primary analysis. Pegloticase exposures were higher than those historically observed with pegloticase monotherapy, and no anaphylaxis or infusion reaction events occurred during the study.

CONCLUSIONS

This improved response rate to pegloticase in the KT population reflects observations from other trials and reports on immunomodulation with pegloticase. As the KT population has a high prevalence of gout and limitations with oral urate lowering medication options, these findings suggest a potential option for uncontrolled gout therapy in KT participants.

Factors associated with change in health-related quality of life in people with gout: a 3-year prospective cohort study in primary care

OBJECTIVE

To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care.

METHODS

In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0-100), 36-item Short Form Physical Function subscale (PF-10; 0-100) and HAQ Disability Index (HAQ-DI; 0-3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years.

RESULTS

A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05).

CONCLUSION

Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

Management of Gout in the Hand and Wrist

Gout, or monosodium urate deposition disease, is the most common form of inflammatory arthritis that affects almost 4% of adults in the United States.Medical management involves lifestyle modifications and urate-lowering therapy to reduce the frequency of gout flares, decrease the tophi size, and improve upper extremity function. Goals for surgical management of gout include functional optimization, symptomatic treatment, and cosmetic restoration.This article focuses on the medical and surgical treatment of the common manifestations of gout in the upper extremity including tophi, tenosynovitis, joint contractures, neural compression, and arthropathy.

Three Cases of Gouty Tophus in the Foot Treated by Resection

We encountered three cases of gouty tophus in the foot that required resection. All patients were male and aged 44-68 years at the time of surgery. The lesions were located on the great toe, second toe, and lateral malleolus and were causing ulceration and destruction of the joints. One patient had normal uric acid levels, and another patient had hyperuricemia but no history of attacks and no significant inflammatory symptoms around the gouty tophus, which was attributed to the physical containment of uric acid crystals by the gouty tophus. Given that the crystals were adherent to the surrounding fibrous tissue and cartilage surface, we resected them as far as possible to reduce the total amount of crystals and treated the remaining crystals with uric acid-lowering therapy. There were no complications at the time of surgery. The swelling and bone destruction subsided with continued medical treatment, resulting in significant improvement in quality of life. Patients with gouty tophus should be treated aggressively with medication and monitored to prevent severe joint destruction and ulceration. Excision of the nodule should be considered in cases of exacerbation.

Establishment and Validation of Predictive Model of Tophus in Gout Patients

(1) Background: A tophus is a clinical manifestation of advanced gout, and in some patients could lead to joint deformities, fractures, and even serious complications in unusual sites. Therefore, to explore the factors related to the occurrence of tophi and establish a prediction model is clinically significant. (2) Objective: to study the occurrence of tophi in patients with gout and to construct a predictive model to evaluate its predictive efficacy. (3) Methods: The clinical data of 702 gout patients were analyzed by using cross-sectional data of North Sichuan Medical College. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were used to analyze predictors. Multiple machine learning (ML) classification models are integrated to analyze and identify the optimal model, and Shapley Additive exPlanations (SHAP) interpretation was developed for personalized risk assessment. (4) Results: Compliance of urate-lowering therapy (ULT), Body Mass Index (BMI), course of disease, annual attack frequency, polyjoint involvement, history of drinking, family history of gout, estimated glomerular filtration rate (eGFR), and erythrocyte sedimentation rate (ESR) were the predictors of the occurrence of tophi. Logistic classification model was the optimal model, test set area under curve (AUC) (95% confidence interval, CI): 0.888 (0.839-0.937), accuracy: 0.763, sensitivity: 0.852, and specificity: 0.803. (5) Conclusions: We constructed a logistic regression model and explained it with the SHAP method, providing evidence for preventing tophus and guidance for individual treatment of different patients.

A Randomized, Placebo-Controlled Study of Methotrexate to Increase Response Rates in Patients with Uncontrolled Gout Receiving Pegloticase: Primary Efficacy and Safety Findings

OBJECTIVE

To assess efficacy, safety, pharmacokinetics, and immunogenicity of pegloticase plus methotrexate (MTX) versus pegloticase plus placebo cotreatment for uncontrolled gout in a randomized, placebo-controlled, double-blind trial.

METHODS

This study included adults with uncontrolled gout, defined as serum urate ≥7 mg/dl, oral urate-lowering therapy failure or intolerance, and presence of ongoing gout symptoms including ≥1 tophus, ≥2 flares in the past 12 months, or gouty arthritis. Key exclusion criteria included MTX contraindication, current immunosuppressant use, G6PDH deficiency, and estimated glomerular filtration rate <40 ml/minute/1.73 m² . Patients were randomized 2:1 to 52 weeks of pegloticase (8 mg biweekly) with either oral MTX (15 mg/week) or placebo. The primary end point was the proportion of treatment responders during month 6 (defined as serum urate <6 mg/dl for ≥80% of visits during weeks 20-24). Efficacy was evaluated in all randomized patients (intent-to-treat population), and safety was evaluated in all patients receiving ≥1 blinded MTX or placebo dose.

RESULTS

A total of 152 patients were randomized, 100 to receive pegloticase plus MTX, 52 to receive pegloticase plus placebo. Significantly higher treatment response occurred during month 6 in the MTX group versus the placebo group (71.0% [71 of 100 patients] versus 38.5% [20 of 52 patients], respectively; between-group difference 32.3% [95% confidence interval 16.3%, 48.3%]) (P < 0.0001 for between-group difference). During the first 6 months of pegloticase plus MTX or pegloticase plus placebo treatment, 78 (81.3%) of 96 MTX patients versus 47 (95.9%) of 49 placebo patients experienced ≥1 adverse event (AE), most commonly gout flare (64 [66.7%] of 96 MTX patients and 34 [69.4%] of 49 placebo patients). Reports of AEs and serious AEs were comparable between groups, but the infusion reaction rate was considerably lower with MTX cotherapy (4.2% [4 of 96 MTX patients, including 1 patient who had anaphylaxis]) than with placebo cotherapy (30.6% [15 of 49 placebo patients, 0 who had anaphylaxis]) (P < 0.001). Antidrug antibody positivity was also lower in the MTX group.

CONCLUSION

MTX cotherapy markedly increased pegloticase response rate over placebo (71.0% versus 38.5%) during month 6 with no new safety signals. These findings verify higher treatment response rate, lower infusion reaction incidence, and lower immunogenicity when pegloticase is coadministered with MTX.

Risk of gout flares after COVID-19 vaccination: A case-crossover study

OBJECTIVE

Routine vaccinations are associated with an increased risk of gout flares. We examined the association between COVID-19 vaccination, an immunization program implemented to a large proportion of population, and the risk of gout flares.

METHODS

We conducted a time-stratified case-crossover study among patients with gout who experienced gout flares between December 2020 and September 2021, using data from The Health Improvement Network. We compared the risk of gout flares on each of the seven days on and after the day of COVID-19 vaccination vs. no vaccination during that period using conditional logistic regression. In addition, we performed subgroup analyses stratified by different COVID-19 vaccines (i.e., BNT162b2, hereafter referred to as BNT, and ChAdOx1 nCov-19, hereafter referred to as ChAd).

RESULTS

Among 5,904 patients with gout (mean age: 63·1 years; 85·5% male) who experienced gout flares within one month, the risk of gout flares slightly increased on the second day after COVID-19 vaccination (odds ratio: 1·44; 95% CI: 1·02 to 2·07). The risk of gout flares also slightly increased after receiving COVID-19 vaccine on other remaining days (ORs ranged from 1·03 to 1·22); however, none of them was statistically significant. An increased risk of gout flares on the second day after vaccination was mainly observed for the ChAd vaccine (odds ratio: 1·44; 95% CI: 1·00 to 2·05), but not for BNT vaccine (odds ratio: 1·18; 95% CI: 0·67 to 2·02).

CONCLUSION

COVID-19 vaccination, mainly ChAd vaccination, slightly increases the risk of gout flares on the second day after vaccination. This finding reassures the safety of COVID-19 vaccination for patients with gout.

Community Practice Experiences with a Variety of Immunomodulatory Agents Co-Administered with Pegloticase for the Treatment of Uncontrolled Gout

Objective

Patients with uncontrolled/refractory gout have heavy disease burden, but few treatment options. Pegloticase lowers serum urate (SU), but anti-drug antibodies can limit treatment efficacy. Evidence supports immunomodulator-pegloticase co-administration to increase sustained urate-lowering rates, but published cases are limited. This study investigated experience with pegloticase-immunomodulation co-therapy at two community rheumatology practices.

Methods

Patients initiating pegloticase with immunomodulation in 2017 or later were included. Patient/treatment characteristics and proportion of responders (≥ 12 pegloticase infusions, SU < 6 mg/dl at infusion-12) were examined. Patients on therapy at data collection with < 12 infusions were excluded from response analyses. eGFR before and after therapy was examined.

Results

Thirty-four patients (79% male, 62.4 ± 16.3 years) with uncontrolled gout (SU = 9.1 ± 2.0 mg/dl, 91% tophaceous) were included. Most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and CKD (47%). Pre-therapy eGFR was 65.4 ± 25.2 ml/min/1.73 m² (41% eGFR < 60 ml/min/1.73 m²). All patients initiated immunomodulation before (5.3 ± 3.0 weeks, n = 32) or at (n = 2) first pegloticase infusion. Subcutaneous methotrexate (15.4 ± 4.9 mg/week, n = 20), oral methotrexate (15.3 ± 3.6 mg/week, n = 9), mycophenolate mofetil (1000 mg/day, n = 3), and azathioprine (100 mg/day, n = 2) were administered. Patients received 14.6 ± 7.1 infusions over 28.5 ± 14.9 weeks. Overall response rate was 89%, ranging among immunomodulators (subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%). On average, eGFR increased during therapy (+ 10.3 ± 16.9 ml/min/1.73 m²), with CKD stability/improvement in 85%. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted. No new safety concerns were identified.

Conclusions

These real-world findings provide further support for increased pegloticase response rates when co-treatment with immunomodulating therapy is used.

Patients with gout that does not respond to oral urate-lowering therapies have heavy disease burden and few treatment options. Pegloticase lowers serum urate levels (SU) and resolves tophi, but anti-drug antibodies can limit urate-lowering efficacy duration. Evidence increasingly supports co-administering an immunomodulator with pegloticase to increase the proportion of patients with sustained urate-lowering response. However, there are few published cases from real-world clinical practice. This study examined treatment with pegloticase + immunomodulation at two community rheumatology practices. Patients who began treatment with pegloticase and an immunomodulator in 2017 or later were included. The proportion of patients with sustained urate-lowering response (≥ 12 infusions received, SU < 6 mg/dl at infusion 12) was investigated. Renal function before and after therapy was also examined. Thirty-four patients were included. Before treatment, SU averaged 9.1 mg/dl and most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and chronic kidney disease (47%). All patients began using an immunomodulator before or at first pegloticase infusion (subcutaneous methotrexate [20 patients], oral methotrexate [9 patients], mycophenolate mofetil [3 patients], and azathioprine [2 patients]). On average, 14.6 infusions were administered over 28.5 weeks and overall response rate was 89%. Response rate varied among different immunomodulators: subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%. On average, kidney function improved, with chronic kidney disease stage stability/improvement in 85% of patients. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted and no new safety concerns were identified. These real-world findings provide further support for administering immunomodulation as co-therapy to pegloticase.

Critical appraisal of serum urate targets in the management of gout

Gout management involves two broad aspects: treatment of gout flares to provide rapid symptomatic relief and long-term urate-lowering therapy to lower serum urate sufficiently to prevent gout flares from occurring. All of the major rheumatology societies recommend a target serum urate of <5 mg/dl (<0.30 mmol/l) or <6 mg/dl (<0.36 mmol/l), both of which are below the point of saturation for urate and therefore lead to monosodium urate crystal dissolution. In this Review, we describe the rationale for treat-to-target urate approach in the long-term management of gout and the current evidence and controversy around the appropriate serum urate targets.

En Masse Excision and Curettage for Periarticular Gouty Tophi of the Hands

BACKGROUND

Despite increasing disease prevalence, there remains a paucity of data examining surgical treatments for gouty tophi. This article assesses en masse excision and curettage of articular tophi involving the hands and shows that carefully planned and precisely executed surgery can consistently alleviate pain, preserve function, and enhance the aesthetics of afflicted hands.

METHODS

A retrospective review was conducted of all consecutive patients who underwent surgical excision of tophaceous deposits from the upper extremity. All patients had an established diagnosis of gout and had been treated with urate-lowering medication. All tophi were substantive in size and were causing significant digital joint dysfunction and disfigurement with variable skin ulcerations.

RESULTS

The study group included 12 patients with 24 tophaceous deposits excised from the metacarpal and interphalangeal joints; 2 deposits were also concomitantly excised from the wrist and 2 from the elbow. The study group included 8 men and 4 women, with an average age of 67 years. Follow-up evaluation ranged from 2 to 15 years. All patients underwent successful tophus excision with restoration of tendon excursion and joint mobility without wound complications. All regained high levels of function, and all reported satisfaction with their outcome. On follow-up for as long as 15 years, recurrence has not been observed and secondary surgery has not proved necessary.

CONCLUSIONS

This study indicates that surgical excision of articular tophi of the hands can provide long-term improvement in function and aesthetics with minimal risk of wound complications or recurrence.

Change in serum urate level with urate-lowering therapy initiation associates in the immediate term with patient-reported outcomes in people with gout

OBJECTIVE

To examine the associations of changes in serum urate (SU) with health-related quality of life (HRQOL) in gout.

METHODS

We used the first 6-months of data from four interventional trials and one observational, open-label study of urate-lowering therapy (ULT) use. HRQOL were assessed at baseline and every 3-months, and SU was measured monthly. Primary outcome measures were Short-form 36 physical and mental component summary scores, Health Assessment Questionnaire Disability Index (HAQ-DI), Sheehan Disability Scale (SDS), Patient Global Assessment, and pain scores in the last week. Linear mixed models for each outcome were adjusted as appropriate for current SU, change in urate in the last month, number of flare-affected days in the last month, baseline BMI, age, comorbidities, sex, ethnicity, trial/study and treatment combination, and tophi status (fixed effects); subject, and the trial/study month were random effects.

RESULTS

Higher current SU correlated with reduced physical and mental HRQOL, and increased SDS and pain but not with HAQ-DI score. In the first 6-months of new/escalating ULT use, absolute change in SU levels associated with poorer outcomes on the HAQ-DI scale (β (95% CI) = 0.013 (0.007-0.019)) and poorer outcomes on SDS, SF-36 MCS, patient global and pain scales. Reduction of SU associated with poorer outcomes in all six measures.

CONCLUSION

High SU levels were associated with poorer HRQOL, pain and Sheehan disability score. Recent SU level fluctuations are associated with poorer outcomes, primarily driven by a reduction in SU. Clinical emphasis on slow rather than fast SU reduction and the routine use of effective, anti-inflammatory medications at ULT initiation/escalation may avoid short-term poor outcomes.

Egyptian consensus on treat-to-target approach of gout: evidence-based clinical practice guidelines for the management of gout

Introduction

New therapies, management approaches, and evidence regarding the management of gout have become available over the past years. This triggered the need for an updated recommendation for gout management. Through an up-to-date consensus evidence-based clinical practice guideline for the management of gout including recommendations for management of gout flares, optimum usage of urate lowering therapy for chronic gout, as well as patient education and lifestyle guidance. A wide systematic literature review was performed, and evidence-based recommendations were extrapolated, based on 16-key questions identified according to population, intervention, comparator, and outcomes (PICO) approach. These were evaluated by a panel consisted of 17 rheumatology experts via online surveys over a 2-round Delphi process. The purpose of this study is to offer an updated, consensus-evidence-based, and in the meantime patient-focused, expert recommendations for the treat-to-target approach of gout management.

Results

Results revealed that after round 2 ended, a total of 30-recommendation items, categorized into 10 domains, were obtained. Agreement with the recommendations (rank 7–9) ranged from 90 to 100%. Consensus was reached (i.e., ≥ 75% of respondents strongly agreed or agreed) on the wording, the grade of recommendation, and level of evidence of all the 30 clinical standards identified by the scientific committee.

Conclusions

This guideline provides updated evidence-based recommendations for the prevention and treatment of acute as well as chronic gout. This guideline provides an approach for physicians and patients making decisions on the management of gout. It will also facilitate improvement and uniformity of care.

Translation, internal consistency, reliability and validity of the Thai version of Gout Assessment Questionnaire version 2.0 (GAQ 2.0)

OBJECTIVES

To translate the Gout Assessment Questionnaire version 2.0 (GAQ2.0) with Gout Impact (GI) Scale (GIS) into Thai and determine its psychometric property in gout patients with acute arthritis (acute arthritis group) and during the intercritical period (chronic gout group).

METHODS

Translation followed the ISPOR recommendations. Cronbach's α, intraclass correlation coefficient (ICC) and standardized response mean (SRM) were used to determine internal consistency, reliability and responsiveness to change, respectively. Correlations between GI subscales with generic health-related quality of life (HRQoL) questionnaires (SF-36, HAQ-DI and EQ-5D-5L) and gout clinical parameters were determined.

RESULTS

The acute arthritis group and the chronic gout group comprised 27 and 92 patients, respectively. Internal consistency was sufficient for all GI subscales (Cronbach's α = 0.80-0.98), reliability was moderate to good in most GI subscales (ICC = 0.54-0.88) and responsiveness to change was moderate to large in most GI subscales (SRM = 0.43-0.98). The GI subscales correlated better with SF-36 than HAQ-DI and EQ-5D-5L. In the acute arthritis group, the unmet gout treatment needs subscale showed large and moderate negative correlation with tophi and serum uric acid, respectively. In the chronic gout group, the gout concern overall subscale had statistically significant, moderate correlation with overall gout severity rated by the patients and number of gout attacks over the past year, while the well-being during attack subscale and total GIS score had statistically significant, moderate correlation with overall gout severity rated by the patients.

CONCLUSION

The Thai GAQ2.0 GIS showed acceptable internal consistency, reliability and responsiveness to change and correlated significantly with generic HRQoL questionnaires and clinical parameters. Key Points • The Thai GAQ2.0 GIS showed acceptable internal consistency, reliability and responsiveness to change in gout patients both during acute attack and during the intercritical period • The GI subscales showed significant correlation with SF-36 and HAQ questionnaires and gout clinical parameters in gout patients both during acute attack and during the intercritical period • The Thai GAQ2.0 GIS subscales should be used in conjunction with generic HRQoL for complete HRQoL assessment in gout patients.

Operative Management of Gouty Tophi in the Region of the Olecranon: A Case Series

Background

Tophaceous gout affecting the olecranon region can result in local discomfort, skin ulceration, secondary infection, and considerable disability if left untreated. However, there are limited reports of outcomes, including postoperative complications and recurrence after surgical excision of tophaceous gout deposits at the elbow. The aim of this study is to present our surgical technique and minimum one-year outcomes after surgical excision of tophaceous gout involving the elbow.

Methods

A retrospective chart review was performed on all patients from a single surgeon's practice who underwent surgical excision of gouty tophi of the elbow between January 2016 and December 2019. The indications for surgical excision of tophi included failure of medical management, presence of skin ulceration, and/or large gouty tophi. The relevant data pertaining to patient demographics, preoperative findings, intraoperative findings, surgical pathology reports, and short-term postoperative complications were collected through retrospective chart review. Patients were subsequently contacted for a follow-up telehealth visit to assess recurrence of gouty tophi, functional outcomes, and range of motion (ROM) measurements.

Results

Six male patients underwent 7 total procedures (1 bilateral elbow) during the study period. The mean age of the cohort at the time of surgery was 56.0 ± 7.1 years (range: 45.3-63.5). The mean size of the swelling in 2 maximum dimensions was 5.8 × 3.4 cm. There were no intraoperative or immediate postoperative wound complications. There was no recurrence of gouty tophi at a mean follow-up time of 30.8 months (range: 14.0-43.5). Patients reported physiologic ROM (mean flexion-extension arc of 2°-134°) with no pain at final follow-up.

Conclusion

Surgical treatment of tophaceous gout of the elbow is associated with a low risk of wound complication and recurrence.

Effect of Leflunomide on Pegloticase Response Rate in Patients with Uncontrolled Gout: A Retrospective Study

Background

Pegloticase, a PEGylated uricase for uncontrolled gout, rapidly lowers serum urate (SU). Not all patients complete a full-therapy course because anti-pegloticase antibodies can develop, causing efficacy loss and infusion reactions. The literature and clinical trial data indicate that methotrexate co-administration markedly improves pegloticase response rates from the established monotherapy response rate of 42%. Unfortunately, methotrexate use is restricted by kidney disease, which is often present in uncontrolled gout patients. Leflunomide is less restricted in patients with renal dysfunction. This study examined the treatment response rate of pegloticase co-administered with leflunomide.

Methods

Patients co-treated with pegloticase (8 mg biweekly infusion) and oral leflunomide (20 mg/day) were included. Patient/treatment characteristics and safety parameters (adverse events [AEs], laboratory parameters) were examined. Pre-infusion prophylaxis was administered (day of infusion: IV solumedrol, night before and morning of infusion: oral fexofenadine or diphenhydramine). Patients were considered treatment responders if ≥ 12 pegloticase infusions were administered and pre-infusion SU < 6 mg/dl at infusion-12.

Results

Ten patients (five male, 72.7 ± 12.5 years) were included. The most common comorbidities were chronic kidney disease (90%), hypertension (70%), diabetes mellitus (60%), obesity (60%), and congestive heart failure (50%). Baseline SU was 7.1 ± 2.4 mg/dl and nine patients (90%) had subcutaneous tophi noted. Seven patients (70%) met responder criteria, receiving 26.6 ± 14.0 infusions (range 13–55) with a pre-infusion-12 SU of 0.9 ± 1.5 mg/dl. The three non-responders received < 12 infusions because of unrelated AEs or loss of follow-up. Three patients (30%) experienced AEs. One had unrelated cardiac disease worsening and three gout flares, one had a pre-infusion solumedrol reaction (wooziness/loss of consciousness), and one had two mild, transient increases in liver enzymes.

Conclusions

This study supports leflunomide as co-therapy to pegloticase in uncontrolled gout patients. Heterogeneity and high comorbidity burden in uncontrolled gout patients makes having a variety of immunomodulators options important.

Gout-associated uric acid crystals induce tophi ulcerations and impair wound healing in a novel gouty ulcer model

This study aimed to establish a novel gouty ulcer rat model induced by monosodium urate (MSU) deposition and preliminarily explored how MSU crystals affected wound healing. MSU crystals were subcutaneously injected into the back of rats to simulate tophi formation and ulceration. Ultrasound was used to detect the formation of gouty tophi. MSU crystal deposition and histopathological changes were analysed by haematoxylin-eosin staining. After the skin over the tophi became broken in the model group, a full-thickness tissue defect of the same area was made on the backs of the phosphate buffered saline (PBS) controls. On Days 3, 7, and 14 after wounding, the infiltration of neutrophils and macrophages and the expression of inflammatory markers, including interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α), and Nod-like receptor protein 3 (NLRP3), were examined by immunohistochemical staining and Western blotting, respectively. After the first subcutaneous injection in rats, local tissues showed redness and swelling, indicating inflammation on approximately Day 14. Tophi-like manifestations appeared on approximately Day 18. Tophi appeared heterogeneously hyperechoic by ultrasound. Swelling and redness in injured tissue areas increased on approximately Day 22, skin tissue necrosis was seen in a small area on approximately Day 26, and skin necrosis was enlarged and the tophi were ulcerated on approximately Day 32, accompanied by yellowish-white, chalky secretions. Haematoxylin and eosin staining showed dermal deposition of needle-like crystals with surrounding granulomatous inflammation. On Days 3, 7, and 14 after wounding, immunohistochemical staining showed the infiltration of neutrophils and macrophages, and the expression of inflammation-related proteins (IL-1β, TNF-α, and NLRP3) were upregulated in gouty ulcers compared with those of PBS controls. The gouty ulcers were not completely healed by Day 14 compared with those in the PBS controls. In this study, a novel gouty ulcer rat model was constructed, which also revealed the existence of persistent chronic inflammation.

Expanding the role of Australian community dietitians in gout management

AIM

Gout is a common form of inflammatory arthritis with suboptimal management. Management guidelines for gout highlight the importance of both pharmacological and non-pharmacological treatments. Dietitians can potentially assist in improving gout's associated dietary and lifestyle factors, and thereby play a role in improving its management. The aim of this study was to investigate perspectives of Australian community dietitians on whether their role in gout management could be expanded to improve management and treatment of gout.

METHOD

A snowballing recruitment strategy was used. Dietitians known to the research team were invited to participate and then they suggested further dietitians. Semi-structured interviews (one-on-one) were conducted with 16 dietitians. The focus was on their experiences of contributing to the management of gout, including any barriers and facilitators experienced. Interviews were transcribed verbatim and independently analyzed by 2 reviewers to identify themes.

RESULTS

The main reported role of dietitians in gout management was providing patient education. An identified facilitator was dietitians' understanding of gout and its dietary management. Barriers included the emphasis placed on medications for treatment by clinicians and patients, consultation costs, limitations in the evidence for the efficacy of dietary changes and lack of specific training in gout for dietitians. Dietitians predominantly managed the other metabolic conditions commonly associated with gout.

CONCLUSION

Currently, the role dietitians play in gout management is limited. However, dietitians have the potential to take on larger roles in gout education and can also indirectly contribute by way of management of commonly associated comorbidities in gout patients.

12-month results from the real-life observational treat-to-target and tight-control therapy NOR-Gout study: achievements of the urate target levels and predictors of obtaining this target

OBJECTIVES

Gout is often not adequately treated, and we aimed to apply urate lowering treatment (ULT) combined with individual information to achieve target serum urate (sUA) in clinical practice, and to identify predictors of achievement of this sUA target.

METHODS

Patients with a recent gout flare and sUA >360 µmol/L (>6 mg/dL) were consecutively included in a single-centre study and managed with a treat-to-target approach combining nurse-led information about gout with ULT. All patients were assessed with tight controls at baseline, 1, 2, 3, 6, 9 and 12 months including clinical examination, information on demographics, lifestyle, self-efficacy and beliefs about medicines. The treatment target was sUA <360 µmol/L and multivariable logistic regression was used to identify predictors of target attainment with ORs and 95% CIs.

RESULTS

Of 211 patients (mean age 56.4 years, disease duration 7.8 years, 95% males), 186 completed the 12-month study. Mean sUA levels decreased from baseline mean 500 to 311 µmol/L at 12 months with 85.5% achieving the treatment target. Alcohol consumption at least weekly versus less frequently (OR 0.14; 95% CI 0.04 to 0.55) as well as beliefs in overuse of medicines (OR per unit 0.77; 95 CI 0.62 to 0.94) decreased the chance of reaching the treatment target, while higher self-efficacy for arthritis symptoms (OR 1.49 per 10 units; 95% CI 1.09 to 2.05) increased the likelihood.

CONCLUSIONS

This study shows that target sUA can be achieved with ULT in most patients. Less self-reported alcohol consumption, low beliefs in overuse of medicines and higher self-efficacy are associated with treatment success.

Treat-to-Target urate-lowering therapy in primary gout patients: A real-world retrospective study at a dedicated gout clinic in China

BACKGROUND

Gout is the most common inflammatory arthritis affecting 1.1% of the population in mainland China with a higher prevalence in coastal areas.

OBJECTIVE

The purpose of the study was to investigate the clinical outcomes following urate-lowering therapy (ULT) in a real-world group study of primary gout patients in China.

METHODS

Electronic medical records of all the gout patients (n= 1588) that visited the Clinical Medical Center of Gout of the Affiliated Hospital of Qingdao University from September 2016 to February 2018 were analyzed in this study. The patients were treated with a standard treat-to-target (T2T) ULT strategy according to the 2016 EULAR Guidelines. Clinical data were collected in the first visit and one-month (defined as the baseline of ULT), 7-month, and 13-month follow-ups were completed.

RESULTS

Amongst the patients in the study, 92.70% accepted ULT and 82.93% completed ULT for 3 months, 63.54% for 6 months, and 40.49% (n= 643) for 12 months. Further analysis of the 643 patients included the following data: the sUA level reduced at month 7 and reduced further at month 13. The gout flares, patient global pain visual analogue score, and health assessment questionnaire score improved at month 7 but did not improve further at month 13, and the index tophus size did not.

Low Back Pain Flares: How do They Differ From an Increase in Pain?

OBJECTIVE

The term flare is commonly used to describe low back pain (LBP) fluctuations, but individuals with LBP consider that it does not always correspond to increased pain. This case cross-over study aimed to: (1) determine the extent to which days with a flare identified according to a multidimensional definition (self-reported flare, SRF) corresponded to days with greater than average pain (pain-defined flare, PDF) and (2) to investigate whether physical and psychosocial features differ between PDF and SRF.

MATERIALS AND METHODS

Individuals with LBP for ≥3 months (N=126) provided data on flares, physical, and psychosocial features daily for 28 days using a smartphone application.

RESULTS

Most days with SRF (68%) did not have greater than average pain (ie, PDF), but most days with greater than average pain (64%) were reported as an SRF. On days with SRF-only all physical and psychosocial features were worse than nonflare days. SRF+PDF had lower sleep quality and higher pain intensity, fatigue, disability, pain catastrophizing, and fear avoidance than SRF-only. SRF+PDF had higher pain in the afternoon and evening, disability and pain catastrophizing than PDF-only. Self-efficacy at work and during leisure activities was worse on SRF+PDF days than SRF-only and PDF-only days.

DISCUSSION

These findings highlight that when individuals with LBP consider they have a flare, they do not always have greater than average pain, but have worse psychosocial features. This emphasizes that flare has broader dimensions than pain alone. Consideration of flare according to broad dimensions is important when investigating symptom fluctuations across different LBP trajectories.

Outcomes of Care Among Patients With Gout in Europe: A Cross-sectional Survey

OBJECTIVE

To assess health- and patient-centered outcomes in gout across Europe, and explore patient-, care-, and country-level characteristics associated with these outcomes.

METHODS

Patients with self-reported physician-diagnosed gout from 14 European countries completed an online survey. Multivariable mixed-effect logistic and linear regressions were computed for health outcomes (gout flare recurrence) and patient-centered outcomes (patient satisfaction with current medication, and unaddressed goals), accounting for clustering within countries. The role of patient-, care-, and country-level factors was explored.

RESULTS

Participants included 1029 patients, predominantly diagnosed by a general practitioner (GP). One or more gout flares were reported by 70% of patients and ≥ 3 flares by 32%. Gout patients reported 1.1 ± 1.2 unaddressed goals, and 80% were satisfied with current medication. Patients with ≥ 3 and ≥ 1 flares were less likely to be treated with urate-lowering therapy (ULT) (OR 0.52, 95% CI 0.39-0.70 and OR 0.38, 95% CI 0.28-0.53, respectively), but more likely to have regular physician visits (OR 2.40, 95% CI 1.79-3.22 and OR 1.77, 95% CI 1.30-2.41). Three or more gout flares were also associated with lower satisfaction (OR 0.39, 95% CI 0.28-0.56) and more unaddressed goals (β 0.36, 95% CI 0.19-0.53). Notwithstanding, the predicted probability of being satisfied was still between 57% and 75% among patients with ≥ 3 flares but who were not receiving ULT. Finally, patients from wealthier and Northern European countries more frequently had ≥ 3 gout flares.

CONCLUSION

Across Europe, many patients with gout remain untreated despite frequent reported flares. Remarkably, a substantial proportion of them were still satisfied with gout management. A better understanding of patients' satisfaction and its role in physicians' gout management decisions is warranted to improve quality of care and gout outcomes across Europe.

Development and Pilot Testing of MyGoutCare: A Novel Web-Based Platform to Educate Patients With Gout

BACKGROUND

Management guidelines have identified unmet educational needs in gout patients. Our objective was to develop and pilot test MyGoutCare (MGC©)-a web-based, interactive educational resource for gout patients, tailored to improve knowledge.

METHODS

The website was developed with input from patients and experts. A health informatics expert tailored content areas so the patient could walk through a journey to learn various aspects of gout. During the pilot study, patients completed baseline demographics and a 10-item validated gout knowledge questionnaire. After reviewing the website, patients completed a post-survey within 2 weeks of their physician visit. Data were analyzed using paired t-tests and effect size (ES) was calculated for the changed scores.

RESULTS

Gout patients and experts agreed on these content areas-triggers of flares, comorbidities, pharmacologic and non-pharmacologic treatment, healthy gout diet, and lifestyle choices. In the pilot study, 50 patients (mean age of 54 years, mean disease duration of 9.5 years, and mean 3-5 flares/year) were recruited. Their post-survey scores (0-10) on knowledge questions improved significantly when compared to pre-survey scores with mean (SD) of 1.95 (1.76) p < 0.0001, ES = 0.95. Patients identified actionable changes moving forward after reviewing the website-decision to continue lifelong urate-lowering therapy, complying with periodic monitoring of serum urate, and making dietary changes.

CONCLUSIONS

Web-based platforms that offer patient-focused materials can serve as a practical tool to address ongoing educational needs of gout patients. Additional studies are needed to evaluate if the website can improve patient-physician communication and lead to better long-term outcomes.

Development of a novel gout treatment patient decision aid by patient and physician: A qualitative research study

BACKGROUND

Gout treatment is not optimized globally, often due to therapeutic inertia by physicians or poor adherence to urate-lowering medications by patients. A patient decision aid (PDA) to facilitate shared decision making (SDM) in gout treatment may overcome these physician-patient barriers.

OBJECTIVE

The study explored the views of physicians and patients on a novel locally designed gout treatment PDA prototype.

DESIGN

Qualitative descriptive design was used to gather data from in-depth-interviews (IDI) and focus group discussions (FGD). Data analysis was via thematic analysis. Emergent themes shaped a revised version of the PDA.

SETTING AND PARTICIPANTS

Adult Asian patients with recent acute gout exacerbations and local Primary Care Physicians (PCP) in Singapore were purposefully chosen. 15 patients with gout and 11 PCPs participated across three IDIs and six FGDs, with the investigators exploring their views of a prototype gout treatment PDA.

RESULTS

Patients and physicians generally concurred with the content and design of the PDA prototype. However, while patients preferred fewer treatment details, the PCPs desired more information. Patients preferred the display of statistics, while PCPs felt that numbers were not relevant to patients. The latter were hesitant to include treatment options that were unavailable in primary care. Both stakeholders indicated that they would use the PDA during a consultation. PCPs would need further training in SDM, given a lack of understanding of it.

CONCLUSION AND PATIENT CONTRIBUTION

Patients will be the prime users of the PDA. While their views differed partially from the physicians, both have jointly developed the novel gout treatment PDA.

Presence of tophi is associated with a rapid decline in the renal function in patients with gout

We aimed to compare clinical characteristics of patients with and without tophi at the time of the diagnosis of gout and investigate the association of tophi and renal function in gout patients. The patients who were first diagnosed with gout at the Kangwon National University Hospital were retrospectively studied. Patients were divided into 2 groups according to the presence of tophi at the diagnosis. We compared clinical characteristics and the progression of renal dysfunction between the two groups. Of 276 patients, 66 (25.5%) initially presented with tophi. Tophi group was older, had a longer symptom duration, and a higher prevalence of multiple joint involvement than those without tophi. In multivariate logistic regression analysis, prolonged symptom duration and multiple joint involvement were significantly associated with increased risk of formation of tophi. The decline in the eGFR was more prominent in patients with tophi than in those without (- 4.8 ± 14.5 vs. - 0.7 ± 11.9 ml/min/1.73 m²/year, respectively; P = 0.039). The presence of tophi was significantly associated with a rapid decline in the eGFR (β = - 0.136; P = 0.042). In conclusion, the presence of tophi was associated with a rapid declining renal function. Therefore, an early diagnosis and closely monitoring of renal function might be important in gout patients with tophi.

Managing hyperuricemia and gout in chronic kidney disease: a clinical conundrum

PURPOSE OF REVIEW

There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD.

RECENT FINDINGS

There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD.

SUMMARY

ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits.

The prevalence of gout and hyperuricaemia in Australia: An updated systematic review

BACKGROUND

Gout continues to increase in prevalence in developed countries with Oceanic countries particularly affected. Both gout and hyperuricaemia are associated with the metabolic syndrome and its sequelae. Recently, the Australian Institute for Health and Welfare (AIHW) reported a prevalence rate of 0.8% which appeared incongruous with other published research. Thus, an updated systematic review was undertaken to review the literature on the prevalence of gout and hyperuricaemia in Australia from data published after 2011.

METHODS

A comprehensive, systematic search was conducted in MEDLINE, Embase and Web of Science in addition to relevant websites to identify research reporting the prevalence of gout and/or hyperuricaemia in Australia from May 2011 until June 2020. Crude gout and hyperuricaemia prevalence data was obtained and presented alongside case ascertainment, time-period, age range and stratified by gender if available.

RESULTS

118 full text articles were screened. 12 articles were included for analysis of gout prevalence. 4 articles were identified for the hyperuricaemia analysis. Wide variation in prevalence figures exist largely due study design and sample age range. Studies using a case definition of self-reported diagnosis of gout reported prevalence rates between 4.5% and 6.8%. The remaining studies used either electronic coding data from general practitioners or wastewater estimation of allopurinol consumption and documented adult prevalence rates between 1.5% and 2.9%. Prevalence increases with age, male sex and over time in keeping with global data. Hyperuricaemia prevalence ranged between 10.5% and 16.6% in Caucasian or an Australian representative population. AIHW estimates applied a chronic condition status, defined as current and lasted or expected to last more than six months, to cases of gout in the Australian National Health Survey. This likely results in an under-estimation in reported Australian gout prevalence rates.

CONCLUSIONS

Gout is highly prevalent in Australia compared to global comparisons and continues to increase over time. Hyperuricaemia prevalence is also high although contemporary data is limited.