Monday, February 10, 2014

A New Venture into the World of Gout

Any rheumatologist having crossed Gout Creek must feel motivated to write about gout. Has anyone else?
Well I've crossed Gout Creek (New Zealand, South Island) and there have been some interesting new studies, so I feel very motivated to put a few ideas together.
We all know that alcohol isn't doing good to gout patients, but beer and liquor are tought to be more harmful than for instance a glass of wine. A new study questions this dogma.
T. Neogi and colleagues published the following study: "Alcohol quantity and type on risk of recurrent gout attacks: An internet-based case-crossover study" (Link: Results: The study included 724 participants with gout (mostly men). The risk of recurrent gout attack was 1.36 for > 1-2 and 1.51 for > 2-4 alcoholic beverages higher compared with no alcohol consumption in the 24 hours prior to the gout attack. Consuming wine, beer, or liquor, all had lead to an increased risk of gout attack. The author's concluded: "Episodic alcohol consumption, regardless of type of alcoholic beverage, was associated with an increased risk of recurrent gout attacks, including potentially with moderate amounts. Persons with gout should limit alcohol intake of all types to reduce the risk of recurrent gout attacks."
I don't think that the "dogma" has been fully refuted, but it seems to be a good idea to point out to gout patients that it's better to avoid alcohol in any form. "Really, no alcohol at all?" As most people have a all or nothing attitude, allowing a teeny weeny bit of wine might ease the way to keep gout patients out of harm.

There have been some interesting papers at the EULAR 2013 Meeting in Madrid, link:

I hadn't yet written on interesting studies on gout, which had been presented at the ACR 2013 Meeting in San Diego. I'll dicuss a couple of these studies here.

J.M.A. Wijnands and colleagues presented an abstract [No. 90]: "Insufficient Evidence For An Increase In Prevalence and Incidence Of Gout: A Systematic Review and Meta-Regression Analysis." Methods: "Pubmed, Embase and Web of Science were systematically searched for primary studies on the prevalence and incidence of gout in the general population." Conclusion: "There was insufficient evidence for an increase in prevalence or incidence of gout in recent years." That's reassuring to hear, but I see more patients with more severe gout in recent years, maybe the rate of referral has changed.

Seong-Kyu Kim and collegues looked at [No. 93]: "Higher Consumption Of Sugar-Sweetened Soft Drinks Increases The Risk Of Hyperuricemia In Korean Population: The Korean Multi-Rural Communities Cohort Study." The study was superbly powered with N=9400. Conclusion: "Higher consumption of sugar-sweetened soft drinks increased the risk of hyperuricemia in the Korean population, showing a differential linear trend for hyperuricemia according to gender."

M. De Vera and colleagues presented [No. 210]: "Medication Adherence In Patients With Gout: A Systematic Review." Conclusion: "This is the first systematic review of medication adherence, with particular focus on gout patients. Adherence rates may vary according to methods used to measure adherence. Overall, synthesis of current evidence suggest that medication non-adherence is substantial in gout. Findings highlight the importance of discussing adherence with gout medications during health care professional encounters with gout patients." Among the studies included in this review, allow me to quote: Zandman 2013. N=7,644, follow up after 6 years, proportion of days covered: more than 80% - 17% of patients were still adherent!

K. Logee and colleagues presented [No. 214]: "Use Of Dual-Energy Computed Tomography In Evaluation Of Axial Gout." Nice pictures! Conclusion: "Dual-energy CT can be used to visualize the presence of axial MSU deposition. This may lead to appropriate diagnosis and management of axial gout while avoiding invasive procedures and erroneous treatment." I think, we're still far away from the second half of the authors' conclusion.

P. Sunkureddi and colleagues presented the following study [No. 1177]: "Efficacy and Safety Of Canakinumab Pre-Filled Syringe Versus Triamcinolone Acetonide In Acute Gouty Arthritis Patients." Conclusion: "CAN-PFS (Canakinumab pre-filled syringe) was superior to TA (triamcinolone acetonide) in relieving pain and reducing risk of new attacks, and had a safety profile similar to CAN-LYO (Canakinumab lyophilized powder). The safety profile was also consistent with that observed in previous CAN-LYO studies. Efficacy and safety of the two CAN (Canakinumab) formulations were comparable." I know that this study won't have much impact on daily life, but I think it's an important study for the one patient we all might see in the next years, where everything else had failed.

K.G. Saag and colleagues looked at [No. 1178]: Effect Of Febuxostat On Serum Urate Levels In Gout Subjects With Hyperuricemia and Moderate-To-Severe Renal Impairment: A Randomized Controlled Trial." Conclusion: "In subjects with moderate-to-severe renal impairment, FEB (febuxostat) urate-lowering was efficacious, with no emergent serious safety issues at 12 m (months). The sUA (serum uric acid) was significantly reduced in subjects receiving either regimen of FEB compared to PLB (placebo)." I guess, febuxostat is now fully established, though the high price might still be a problem.

S. Baumgartner and colleagues looked at [No. 1189]: "Allopurinol Dose Titration and Efficacy: A Large-Scale, 6-Month, Multicenter, Prospective Study." Conclusion: " In this large, multinational, prospective observational study of gout, optimal allopurinol dose escalation occurred infrequently. Fewer than 50% of patients overall achieved target sUA level greater than 6.0 mg/dL and the majority of those with a baseline dose of or higher than 300 mg/day did not increase their dose. These data, consistent with published literature, likely reflect real-world circumstances in which a significant proportion of patients fail to reach sUA targets with allopurinol therapy as currently used." PDCA! We have good plans (plan), we put them into practice (do), we have to check more consequently (check), and act - increase the dosage. Hopefully, patients won't leave this quality improving cycle.

F. Perez-Ruiz and colleagues presented [No. 1191]: Low-Dose Anakinra Is Effective For The Prophylaxis Of Acute Episodes Of Inflammation In Severe Tophaceous Gout." Conclusion: "This pilot study is, to our knowledge, the first to prospectively explore in pre-established doses the efficacy of low-dose anakinra for the prophylaxis of AEIs in patients with severe comorbidities and difficult to treat tophaceous gout."

R.T. Keenan and colleagues presented [No. 1193]: "Target Tophus Size and Complete Response Rates In Patients Treated With Open-Label Pegloticase For Chronic Gout Refractory To Conventional Therapy." Conclusion: "Many small and medium subcutaneous tophi resolved within the first 6 months of pegloticase therapy. These data show that substantial incremental benefit in tophus response for unresolved small to medium tophi can be gained with 9–12 months of therapy in UA responders." I have seen patients, who would benefit from pegloticase, but there are problems with getting an appoval by insurance companies as it's an off-label use.

There were lots of interesting studies on gout at both the EULAR 2013 Meeting in Madrid and the ACR 2013 Meeting in San Diego. Let's hope that we can counsel patients even better now.

Picture of tophous gout

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