Acute debilitating painful inflammation, frequently involving the joints in the lower extremities, characterizes the clinical presentations of gout. The deposition of monosodium urate crystal in joints and soft tissues because of elevated serum uric acid (sUA) concentration >6.8 mg/dL causes inflammation and pain.1 In addition to the significant effect on quality of life, untreated or suboptimally treated crystal deposition can lead to chronic manifestations, including disease persistence, increased number of flares, development of tophi, and structural joint damage.
The inflammation, even in asymptomatic patients, can also result in various comorbidities, including hypertension, cardiovascular disease, renal impairment, hyperlipidemia, diabetes, and metabolic syndrome. In fact, gout is associated with an increased risk for death because of cardiovascular disease comorbidity.1,2 For the 9.2 million people in the United States with gout,3 prompt diagnosis and treatment are critical to effective management of the disease and are key determinants of outcome. Given that approximately two-thirds of patients with gout in the United States are diagnosed and treated in the primary care setting, the effective management of gout in this setting is critical.2
Despite the improved treatment options and updated guidelines, the general consensus is that gout is poorly managed in the primary care setting.1,4 The limitations that result in suboptimal patient care and outcomes include a lack of adherence to treatment guidelines by healthcare providers (HCPs), patients’ poor adherence to therapy, and differences between the HCP’s and patient’s perspectives regarding treatment.5 Knowledge gaps can result in failure of HCPs to educate patients about the risk factors for gout, its development, and treatment. The importance of diet and lifestyle modifications and appropriate screening for comorbidities should also be recognized as an integral part of the gout management strategy and communicated to patients.5
The need to improve gout treatment has prompted the evaluation of current practices and formulation of strategies to improve patient care. Education is essential so that patients become knowledgeable partners with the HCP to optimize care.1,6 A nurse-led multidisciplinary, interactive patient-centered approach that recognizes and accommodates the influences of culture, race, and ethnicity has been shown to enhance gout educational interventions and improve gout management.6
Although patient education is an important component in the overall gout management strategy, the initiation of urate-lowering therapy (ULT) is the primary and effective treatment approach. Improving the care of the patient with gout requires HCPs to promptly diagnose gout and be confident in using ULT, adopting a treat-to-target strategy as recommended in guidelines by the American College of Rheumatology (ACR), the European League Against Rheumatism, and the British Society of Rheumatology.7-9 This requires HCPs to know when to start ULT, how long to treat, and the optimal sUA level to attain. The current diagnostic approaches and treatment guidelines can, however, be unspecific and create confusion that perpetuates suboptimal gout management (eg, the 1977 ACR diagnostic criteria are often used for the diagnosis of gout, according to rapid swelling of the affected joint and confirmed with synovial fluid analysis).10 The criteria, however, make no allowance for asymptomatic hyperuricemia that can perpetuate subclinical CVD.
Furthermore, the challenges of differential diagnosis may result in considerable diagnostic delay and suboptimal treatment.11,12 Ultrasonography has been recognized as a useful tool for more accurate detection of crystal deposits, even in asymptomatic individuals13,14; however, the specificity and clinical use of imaging studies as a diagnostic tool are still being evaluated.15
When to start ULT, what to use, and how long to treat are questions faced by physicians that can affect prompt gout management. The ACR and the European League Against Rheumatism guidelines for the treatment of acute gout flares advocate early initiation of ULT during acute gout flare.7,8 These guidelines are, however, less specific on the sUA level that is indicative for treatment initiation. For example, whereas the guidelines from the European League Against Rheumatism and the American College of Physicians on the management of acute and recurrent gout recommend initiating treatment for acute gout flare, particularly for patients with comorbidities and/or sUA level >8 mg/dL,7,16 the ACR guidelines are less clear on the sUA level to initiate treatment.8
Although the guidelines make recommendations for the use of various pharmacologic agents,7-9 with some discussion of comparative effectiveness of different treatment options,8 there is lack of clarity on the safety and efficacy of each treatment option and duration of treatment. All the guidelines agree that attaining sUA <6 mg/dL is associated with fewer gout flares. The American College of Physicians clearly acknowledges the lack of clinical studies to guide prescriptive recommendations for the treatment of gout.8
Golenbiewski and Keenan acknowledge the challenges and limitation of the current treatment of gout. They provide a comprehensive discussion of the benefits, adverse effects, and safety issues associated with pharmacologic agents and acknowledge the value of the nonpharmacologic approach, and the importance of regular patient monitoring.1 As new agents are developed to address unmet medical needs for the treatment of gout,17 and with updated ACR gout guidelines on the horizon, with anticipated publication in late 2019 or early 2020,18 there is hope for the improved care of patients with gout.
Golenbiewski and Keenan clearly identify the need for ongoing patient and provider education to address knowledge gaps and research to provide evidence-based recommendations for ULT initiation, duration, and intensity of treatment to achieve long-term disease control.
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3. Chen-Xu M, Yokose C, Rai SK, Pillinger MH, Choi HK. Contemporary prevalence of gout and hyperuricemia in the United States and decadal trends: the national health and nutrition examination survey 2007-2016 [published online January 7, 2019]. Arthritis Rheumatol. doi:10.1002/art.40807
4. Rogenmoser S, Arnold MH. Chronic gout: barriers to effective management. Aust J Gen Pract. 2018;47(6):351-356.
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13. Puig JG, Beltrán LM, Mejía-Chew C, Tevar D, Torres RJ. Ultrasonography in the diagnosis of asymptomatic hyperuricemia and gout. Nucleosides Nucleotides Nucleic Acids. 2016;35(10-12):517-523.
14. Ebstein E, Forien M, Norkuviene E, et al. Ultrasound evaluation in follow-up of urate-lowering therapy in gout: the USEFUL study. Rheumatology (Oxford). 2019;58(3):410-417.
15. Ogdie A, Taylor WJ, Neogi T, et al. Performance of ultrasound in the diagnosis of gout in a multicenter study: comparison with monosodium urate monohydrate crystal analysis as the gold standard. Arthritis Rheumatol. 2017;69(2):429-438.
16. Qaseem A, McLean RM, Starkey M, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Diagnosis of acute gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):52-57.
17. Bardin T, Richette P. Novel uricosurics. Rheumatology (Oxford). 2018;57(suppl_1):i42-i46.
18. Guideline for the management of gout (final publication of updated guideline anticipated in early 2020). American College of Rheumatology. Accessed May 7, 2019.