Thursday, December 6, 2012

ACR2012 Abstracts on Gout without drug studies

This week I’ve been reviewing abstracts on gout as I’ve written a text in German on gout and participated in an online conference on gout. When I looked through the abstracts on gout at the 2012 ACR meeting in Washington, I was surprised on how many abstracts weren’t related to drugs.

A. Jebakumar and colleagues looked at the co-existence of gout in rheumatoid arthritis as a popular belief is either rheumatoid arthritis or gout. They found gout in patients with RA, but at a lower rate than the normal population. The reasons are unclear. Maybe RA patients keep a diet lower in purines, maybe RA patients drink less alcohol/beer. All in all a very interesting study and topic.
Co-Existence of Gout in Rheumatoid Arthritis: It Does Happen! A Population Based Study.
Adlene Jebakumar, Cynthia S. Crowson, P. Deepak Udayakumar and Eric L. Matteson. Mayo Clinic, Rochester, MN
Conclusion: Gout does occur in patients with RA though at a lower rate than in the general population, with a minimum/maximum cumulative incidence of 1.3/5.3%. Risk factors for gout in RA generally mirror those in the general population.

M. Andres reported on ultinational evidence-based recommendations for diagnosis and treatment of gout. As I had been part of the German panel to vote on expert opinions and take part in discussions, I have been looking for this poster with a special interest. The 10 recommendations were shown on the poster with levels of agreement. No exceptional recommendation.
Multinational Evidence-Based Recommendations for Diagnosis and Management of Gout: Integrating Systematic Literature Research and Expert Opinion of a Broad Panel of Rheumatologists in the 3E Initiative.
Mariano Andres1, Francisca Sivera2, Alison Kydd3, John Moi4, Rakhi Seth5, Melonie K. Sriranganathan6, Caroline van Durme7, Irene AAM van Echteld8, Ophir Vinik9, Mihir D. Wechalekar10, Daniel Aletaha11, Claire Bombardier9, Rachelle Buchbinder12, Loreto Carmona13, Christopher J. Edwards14, R. Landewe15 and De’sire’e van der Heijde16.
Conclusion: Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, thus enhancing their utility in clinical practice.

G.S. Breuer an colleagues published on dual-energy CT, which allows to show uric acid deposits. To my knowledge there isn’t any established method to determine the success of a therapy on tophi reduction. This technique could be used for this purpose. I think the company of pegloticase might welcome this method to show the success on tophi.
Dual-Energy Computed Tomography As a Diagnostic Tool for Gout During Intercritical Periods.
Gabriel S. Breuer1, Naama Bogot2 and Gideon Nesher1
Conclusion: In asymptomatic hyperuricemic patients with a history of recurrent short-lived mono- or oligo-arthralgia or arthritis, DECT identified urate crystals in 50%, confirming a diagnosis of gout. DECT is a valuable tool in diagnosing gout during intercritical periods.

And another study on this topic by Fiona M. McQueen, who had been talking on MRI here in Düsseldorf about 2-3 years ago, and colleagues.
Magnetic Resonance Imaging Versus Dual Energy Computed Tomography for Detection of Joint Pathology in Gout.
Fiona M. McQueen1, Anthony Doyle1, Quentin Reeves2, Angela Gao2, Amy Tsai2, Gregory
Gamble1, Barbara Curteis1, Megan Williams2 and Nicola Dalbeth1.
Conclusion: MRI has moderate to high reproducibility for assessment of gouty arthropathy and strong construct validity for detecting tophi when compared with DECT.

W. Taylor and colleagues aimed at a preliminary definition of remission from gout. It is interesting that serum uric acid (SUA), tophi, and flares are best to discrimate between remission and non-remission, but I personally still think that a SUA of 0.36 mmol/l (6.0 mg/dl) is too high. Nontheless the study has be nicely done
Towards a Preliminary Definition of Remission From Gout.
William Taylor1, Nicola Dalbeth2, Jasvinder A. Singh3, Kenneth G. Saag4 and H. R. Schumacher5.
Conclusion: The domains that showed the greatest discrimination between remission and non-remission were SUA, tophi and flares. Pain between flares did not appear to discriminate between remission and non-remission status. The following definition of remission is proposed, based approximately on the maximal values observed in those who attained remission: SUA no more than 0.36 mmol/l AND no gout attacks in prior 3 months AND no tophi AND patient global assessment no more than 3 (0 to 10 scale).

L.K. Stump and colleagues ventured into the supplementation universe. The idea of giving high doses of vitamin C to use its uricosuric effect isn’t new, but it hadn’t been tested. As benzbromaron and probenecid are added to allopurinol, why not trying vitamin C? The authors, however, didn’t find any significant urate lowering effect. The authors discuss higher doses, but I think that orthomolecular medicine is a dead end.
Lack of Effect of Supplemental Vitamin C On Serum Urate in Patients with Gout.
Lisa K. Stamp1, Christopher Frampton1, John L. O’Donnell2, Jill Drake3 and Peter T. Chapman3.
Conclusion: In this study supplemental vitamin C at modest dose (500mg/d) for 8 weeks had no significant urate lowering effect in patients with gout despite increasing plasma ascorbate concentrations. These results differ from findings in hyperuricaemic healthy controls. The uricosuric effect of modest dose vitamin C appears less in patients with gout both as monotherapy and in combination with allopurinol. Whether larger doses will be effective remains to be determined.

Y. Zhang and collaegues looked at hospitalized patients and found an increased risk for gout attacks.
Increased Risk of Recurrent Gout Attacks During Hospitalization.
Yuqing Zhang1, Clara Chen2, Hyon K. Choi3, Christine E. Chaisson2, David J. Hunter4 and Tuhina Neogi5.
Conclusion: Our study confirmed that the risk of gout attacks increases during hospitalization. These data support the consideration of the provision of appropriate prophylaxis to patients with pre-existing gout
during hospitalization.


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