UK Updates Gout Management Guidelines

Anyone who has awakened in the night acutely aware of the sharp, stabbing pain in his or her big toe is familiar with the pain of gout. The condition, which is not limited to feet alone but can affect all joints, can be so severe that just brushing the afflicted area with a light bedsheet causes excruciating pain.

Uric Acid Levels. However, based on evolving research, there is a new focus on administering urate-lowering drugs (which have been available for more than 50 years) for patients in the early course of the disease, rather than waiting for them to develop severe, sometimes disabling symptoms. Gout results from monosodium urate crystal deposits. Uric acid crystals release inflammatory chemicals called cytokines that can cause pain, swelling, and redness. Dissolving these uric acid crystals, thus lowering the urate level, helps prevent flareup and joint damage. Hyperuricemia, a metabolic disorder, leads to the deposit of these crystals.

For most patients, a serum urate level of 6 mg/dL is a target, though those with severe gout should aim for 5 mg/dL, the guidelines recommend. When serum urate levels are lowered below the monosodium urate saturation point, new crystal formation is prevented, and existing crystals dissolve, leading to a gout “cure.”

New Guidelines. The British Society for Rheumatology has amended previous guidelines, set in 2007, for gout management. Key changes include:

• Emphasis on patient education about gout and its treatment in order to manage acute attacks
• Modification of lifestyle and risk factors
• Optimal use of urate-lowering therapies
• Other recommendations include:
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, or colchicine are both drugs of choice for acute gout when there are no contraindications.
• The choice of first-line agent should be determined by renal function, co-morbidities and patient preference.
• Combinations of NSAIDs with corticosteroids or colchicine can be used for acute attacks where response to a single drug is insufficient.
• IL-1 inhibitors (interleukin-1, anti-inflammatories) may be considered in patients who have not responded adequately to standard treatment.

CVD Risk Factors. The revised guideline emphasizes that all patients with gout should be screened for cardiovascular risk factors and co-morbid conditions such as cigarette smoking, hypertension, diabetes mellitus, dyslipidemia, obesity and renal disease at least annually and treated for these factors.

Although the revised guideline still recommends reduction of uric acid (sUA) with uric acid lowering therapy (ULT) to a target of 300 mmol/l (5.4 mg/dL), ULT dose adjustment to the less stringent sUA target of 360 mmol/l (6.4 mg/dL) is now recommended after some years of successful ULT when tophi (deposits of uric crystal acids under the skin or in a joint) have resolved and the patient remains symptom-free.

Conditions/Diseases Linked with Gout. High uric acid levels are associated with other conditions and diseases besides gout, and can affect kidneys and blood vessels.

Kidney stones are a common problem in people with gout, affecting one in five patients. Kidney stones, besides causing pain, can block the urinary tract, ultimately causing infection and other damage. Conversely, kidney disease can lead to gout. Diabetes is a risk for those with gout, possibly resulting from high cholesterol and high blood pressure. Sleep apnea also is associated with gout, possibly because breathing cessation—oxygen deprivation—can cause uric acid to be overproduced in the blood. Cardiovascular disease is also linked with gout because high levels of uric acid can cause inflammation in blood vessels, which can lead to artherosclerosis. Gout also is associated with certain cancers, particularly prostate cancer, although the extent is not fully understood.

What You Can Do. Self-help preventive steps include dietary changes—avoiding alcohol, limiting red meat, shellfish, and sugary, fructose- and corn syrup-sweetened soft drinks. In addition, lose weight if obesity is an issue, and stop smoking. When you are undergoing a gout attack, ice and rest are adjunct therapies to medication. Most important is to be proactive, and partner with your doctor to alleviate or banish symptoms.

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