Optimizing current treatment of gout

Journal name:
Nature Reviews Rheumatology
Volume:
10,
Pages:
271–283
Year published:
DOI:
doi:10.1038/nrrheum.2014.32
Published online

Abstract

Gout is the most common inflammatory arthritis worldwide. Although effective treatments exist to eliminate sodium urate crystals and to 'cure' the disease, the management of gout is often suboptimal. This article reviews available treatments, recommended best practice and barriers to effective care, and how these barriers might be overcome. To optimize the management of gout, health professionals need to know not only how to treat acute attacks but also how to up-titrate urate-lowering therapy against a specific target level of serum uric acid that is below the saturation point for crystal formation. Current perspectives are changing towards much earlier use of urate-lowering therapy, even at the time of first diagnosis of gout. Holistic assessment and patient education are essential to address patient-specific risk factors and ensuring adherence to individualized therapy. Shared decision-making between a fully informed patient and practitioner greatly increases the likelihood of curing gout.

At a glance

Figures

  1. Metabolism of uric acid and risk factors for gout.
    Figure 1: Metabolism of uric acid and risk factors for gout.

    Crystallization of MSU occurs when uric acid levels exceed the saturation point, through inefficient elimination or excessive production of uric acid. The multiple risk factors for the formation of urate crystals are shown in yellow boxes at their sites of action. Abbreviation: MSU, monosodium urate.

  2. Metabolism and mechanisms of action of colchicine.
    Figure 2: Metabolism and mechanisms of action of colchicine.

    After oral administration and gastrointestinal absorption, colchicine is primarily metabolized by the liver but undergoes substantial enterohepatic circulation. Its pharmacological effects are multiple and varied. Colchicine is excreted primarily in faeces but also in urine.

  3. Management of acute gout attack.
    Figure 3: Management of acute gout attack.

    a | Example of an acute attack at the first metatarsophalangeal joint, known as 'podagra'. b | Aspiration of an acutely inflamed joint; note the turbidity of the synovial fluid. Aspiration followed by injection of corticosteroids is safe, rapidly reduces the extreme pain of acute gout and enables confirmation of the diagnosis. In a hospital setting such treatment, especially in an ill patient with multiple comorbidities, should be considered best practice.

  4. [ldquo]Punch cures the gout, the colic, and the 'tisick[rdquo] (anonymous).
    Figure 4: “Punch cures the gout, the colic, and the 'tisick” (anonymous).

    Historical sterotypes of gout persist and can act as barriers to adequate care.

  5. Mechanism of action of uricosuric drugs at the proximal renal tubule.
    Figure 5: Mechanism of action of uricosuric drugs at the proximal renal tubule.

    Uricosuric drugs licenced for gout (shown in blue boxes) act on URAT1 to prevent re-uptake of uric acid and thus increase its renal excretion. As this is a simplified schema, not all transporters are shown. Abbreviations: OAT, organic anion transporter; GLUT9, glucose transporter type 9; URAT1, urate anion exchanger 1.

  6. Graph representing clearance induction and maintenance phases of therapy for gout.
    Figure 6: Graph representing clearance induction and maintenance phases of therapy for gout.

    In the induction phase, ULT reduces the SUA level to well below the saturation threshold (indicated by the dashed line), to enable dissolution of existing crystals and 'cure' of gout. In the maintenance phase, ULT is reduced following this 'cure', and the SUA level is allowed to rise to just below the threshold for maintenance. Abbreviations: MSU, monosodium urate; SUA, serum uric acid; ULT, urate-lowering therapy.

  7. A full and holistic assessment followed by individualized patient education is core to the management of people with gout.
    Figure 7: A full and holistic assessment followed by individualized patient education is core to the management of people with gout.

    In this instance, a specialist nurse practitioner is assessing a patient and her explanation of his chronic tophaceous gout, its treatment options, and the likely benefits he can expect from ULT will be backed up by focused patient literature. Written consent for publication was obtained from the patient and nurse. Image provided courtesy of M. Doherty.

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Author information

Affiliations

  1. Division of Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital Nottingham, Hucknall Road, Nottingham NG5 1PB, UK.

    • Frances Rees,
    • Michelle Hui &
    • Michael Doherty

Contributions

All authors made substantial contributions to discussions of content, writing, and reviewing/editing the manuscript before submission.

Competing interests statement

M.D. has received honoraria for being a member of ad hoc Advisory Boards for Ardea Biosciences, Menarini, Novartis and Savient. M.H. and F.R. declare no competing interests.

Corresponding author

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Author details

  • Frances Rees

    Frances Rees, BMedSci BMBS MRCP(UK) graduated from the University of Nottingham, UK, in 2005 and is a now a Rheumatology Speciality Trainee in the East Midlands. She is currently undertaking a PhD within the department of Academic Rheumatology at the University of Nottingham, on the epidemiology of SLE and reducing delays to diagnosis. Her research interests include connective tissue diseases, gout and vasculitis.

  • Michelle Hui

    Michelle Hui, MBChB MRCP (Rheumatology) is a full-time Consultant in Rheumatology at the Countess of Chester Hospital, Chester, UK, having graduated from Leicester Medical School in 2004 and completing her Rheumatology training in the East Midlands deanery in 2012. Her clinical interests include musculoskeletal ultrasound used regularly in the clinical setting and with teaching. She is a member of the British Society for Rheumatology Gout Management Guideline Group and has published in peer-reviewed journals.

  • Michael Doherty

    Michael Doherty, MA MD FRCP FHEA (UK) was a scholar of St John's College Cambridge, and completed his undergraduate training at the Middlesex Hospital, London, UK. He was an Arthritis Research UK Rheumatology Research fellow in Bristol and Bath, and is currently Professor of Rheumatology and Head of Academic Rheumatology at the University of Nottingham, UK. His principal research interests are: epidemiological, genetic and clinical aspects of osteoarthritis; community-based clinical trials; gout and calcium pyrophosphate crystal deposition; and evidence-based practice and guideline development. He was awarded the OARSI Clinical Research Award in OA for 2012.

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