Monday, July 15, 2013

Gout at the EULAR 2013 Meeting in Madrid

There were far too many posters, talks, abstracts, etc. at the EULAR 2013 Meeting in Madrid than to comment on everything. So I select my personal highlights and updates.

B. Manger [SP0006] talked on “Visualising crystals: DECT and more”. “Dual energy computed tomography (DECT) is an imaging method, which uses X-ray beams of two different energies to differentiate solid sodium urate deposits from connective tissues and from calcium containing structures by their absorption properties.” “…,DECT may not only be a very helpful imaging method for tophus assessment and follow-up in clinical trials and during urate lowering therapy in patients with the established diagnosis of chronic gout. It may also be valuable as differential diagnostic tool in patients with “unclassified” acute or relapsing arthritides, when aspiration of synovial fluid is not possible or not successful.“
I haven’t used DECT yet and also don’t know, where to look for someone, who is experienced in this method, here in the vicinity.

S.-J. Kee and colleagues studied [OP0002]: “Pathomechanism of bone destruction in chronic gouty arthritis”. “MSU [monosodium urate monohydrate] crystals induced the expressions of IL-1, IL-6, TNF-alpha and RANKL in PBMCs [peripheral blood mononuclear cells], but inhibited OPG [osteoprotegerin] expression.” Conclusions: “ …, our data show that MSU crystals have the potential to induce pro-resorptive cytokines, and T cells are involved in osteoclastogenesis in chronic gout.” Good basic research, which might lead to understand, why erosive lesions look different in gout and RA for instance.

T. Cooper and colleagues presented a study [FRI0568-PC]: “Gout: are we getting it right in primary care? An audit of serum uric acid level measurement and monitoring.” Methods: “This study audited one general practice in the UK.” Results: “A total of 125 patients had received allopurinol in the 3 year period. 76 patients (60.8%) had not had their SUA level measured, leaving only 49 (39.2%) who had their SUA levels checked. …”. Conclusions: “Clearly the majority of patients receiving allopurinol in this general practice were not having their SUA levels measured, being treated to target or monitored annually. If these simple tests and management strategies were performed in primary care then a large number of hospital admissions for attacks of gout could be avoided, with the accompanying save in expenditure. …”
So, it’s important to have revisits by the patient, who have been presented to rheumatologists in order to help our colleagues in primary care, once we’ve seen these gout patients as I presume they suffer from more severe or complicated forms of gout.

D. Chandrasekaran and colleagues presented [SAT0363]: “Evaluation of the use of colchicine in the management of chronic gout.” The authors looked at 515 patients taking colchicines. Conclusions: “… a significant percentage of gout patients are inappropriately on long-term colchicine with only 26% having serum uric acid levels at or below the target level of 6 mg/dl.”
I may add that some GPs don’t read the letters, maybe because the patients don’t show up or maybe because they think that the gout problem has been solved, once the arthritis has been treated. With us rheumatologists there rests an educational responsibility – we have to both educate our referring colleagues as well as our gout patients, whom we normally see only sporadically.  

D. Khanna and colleagues looked at [SAT0384]: “Patients that continue to flare despite reaching EULAR/ ACR recommended serum urate target.” Conclusions: “Less than 50% of patients treated with a XOI inhibitor alone reached sUA target. Of the patients achieving a sUA level of < 6 mg/dL, over a third reported 2 or more flares in a 12-month period.”
Can you see gout patients, who do not flare? I can’t as our outpatient department is only allowed to see patients suffering from severe auto inflammatory diseases. How can we help then? Wait till the poor patients flares again? I don’t have an easy answer.

Gout is a topic that lots of colleagues outside the rheumatologic world feel fit in, but there are still gaps to be filled. I read out of the above studies, that we as rheumatologists have an educational responsibility owards colleagues in primary care and patients as well.

More on gout:
Gout / subcutaneous depots of uric acid

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