Intensive oral urate-lowering therapy (ULT) does not improve bone erosion scores and leads to a higher medication burden in patients with erosive gout, according to results of a randomized double-blind controlled study published in Arthritis and Rheumatology.
Emerging data show that intensive serum ULT may lead to erosion healing in gout. Both the 2012 American College of Rheumatology (ACR) gout management guidelines and the 2016 updated European Alliance of Associations for Rheumatology (EULAR) gout management guidelines recommend that the serum urate target for patients with severe gout, including those with chronic arthropathy, is less than 0.30 mmol/L (5 mg/dL).
Researchers of the current study sought to determine whether intensive oral ULT to maintain serum urate concentrations of less than 0.20 mmol/L vs less than 0.30 mmol/L resulted in improved bone erosion scores in erosive gout.
Eligible patients were 18 years and older and diagnosed with gout as defined by the 2015 ACR/EULAR classification criteria. The primary outcome of the study was total computed tomography (CT) erosion score. Secondary endpoints included Outcomes Measures in Rheumatology (OMERACT) gout core outcome domains (gout flares, tophi, pain, patient global assessment, health-related quality of life, and activity limitation).
A total of 104 participants were included in the study who were randomly assigned 1:1 to a serum urate target of less than 0.20 mmol/L (intensive-target group) or less than 0.30 mmol/L (standard-target group).
Results of the study indicated significantly lower serum urate levels in patients in the intensive-target group compared with those in the standard target group (P =.002). However, at 2 years, fewer participants in the intensive-target vs standard-target group achieved the serum urate target of less than 0.20 mmol/L (62% vs 83%; P <.05). In addition, participants in the intensive-target group required higher allopurinol doses compared with those in the standard-target group (mean, 746 mg/day vs 496 mg/day; P <.001). They also used more combination therapy (P =.0004).
Over a period of 2 years, a small increase in CT erosion scores was observed among participants in both the groups, with no between-group difference (P =.20). Similarly, OMERACT core outcome domains improved in both groups, with no between-group difference.
Limitations of the study included the limited generalizability of the findings to patients with gout and restricted access to a broad range of urate-lowering agents.
Researchers concluded, “Compared with a serum urate target below 0.30 mmol/L, more intensive serum urate-lowering is difficult to achieve with oral ULT, leads to high medication burden, and does not improve bone erosion scores in erosive gout.”
Dalbeth N, Doyle AJ, Billington K, et al. Intensive serum urate lowering with oral urate-lowering therapy for erosive gout: a randomized double-blind controlled trial. Arthritis Rheumatol. Published online December 20, 2021. doi:10.1002/art.42055. doi:10.1002/art.42055