An international panel of leading gout experts has published new recommendations advising that doctors use a treat-to-target approach for managing gout, a painful form of arthritis that affects more than 8 million adults in the United States. Central to the recommendations is using medication to reduce and keep blood uric acid levels below 6 milligrams per deciliter (mg/dL) – and even lower in people with severe gout. The recommendations were published online in Annals of the Rheumatic Diseases in September.
Treat-to-target – a method in which doctors identify specific targets relevant to a disease and adjust medications until that target is reached – is already being used to manage certain chronic diseases, including rheumatoid arthritis, high blood pressure and diabetes.
How Gout Develops
Gout, the most commonly diagnosed inflammatory arthritis in the U.S., occurs when uric acid builds up in the blood (called hyperuricemia) and forms needle-like crystals that are deposited around the joints – often in the big toe, but also in the feet, ankles, knees, wrists and elbows – leading to acute attacks of intense pain, redness and swelling. An attack passes in about a week to 10 days, and is typically treated with medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids and colchicine (Colcrys, Mitigare).
But after an attack subsides, the disease typically doesn’t go away. More than 80 percent of people who have an attack have another within three years, if uric acid levels remain high. The condition can progress, leading to chronic pain, more frequent but milder attacks, tophi (hard, uric acid deposits under the skin) and permanent joint damage. Gout and hyperuricemia are also associated with other health problems, such as high blood pressure, diabetes, metabolic syndrome, cardiovascular and kidney disease.
Evolving Gout Treatment Protocol
Current treatment of gout often entails prescribing allopurinol, which lowers uric acid levels, up to the recommended daily dose and stopping there, regardless of results, says Jonathan Kay, MD, co-author of the recommendations and director of clinical research in rheumatology at UMass Memorial Medical Center in Boston.
“A doctor gives the medication and hopes that [the patient does] well,” Dr. Kay says. “But with gout, the clear target is uric acid. It has been shown that if you maintain levels below 6 mg/dl it controls gout better … so adopting the treat-to-target approach makes sense.”
The treat-to-target recommendations developed by the expert panel state that blood levels of uric acid should be measured regularly and medication adjusted until it reaches 6 mg/dl or lower. Once that level is attained, the patient should be monitored regularly to ensure the target level is maintained. Patients with severe gout should target a uric acid level of 5 mg/dl or lower.
Another recommendation is to provide ample education to patients regarding risk factors for future attacks and treatment. This is important because gout results from a combination of genetic and modifiable lifestyle factors [link to: http://www.arthritis.org/about-arthritis/types/gout/causes.php]. While people with a family history of gout are at higher risk for the disease, being overweight also increase risk of developing gout, and consuming sugary drinks or excessive amounts of alcohol and eating certain foods can increase the risk of an attack.
In the report outlining the recommendations, the expert panel noted a weak spot: Because there are no studies comparing patients who were treated-to-target to those received “routine care,” the recommendations are based on expert opinion and consensus rather than scientific data.
However, Jasvinder Singh, MD, a rheumatologist and professor at the University of Alabama at Birmingham’s School of Medicine, believes there is abundant evidence that uric acid levels need to remain low to reduce the risk of flares and that aiming for less than 6 mg/dl level is a good threshold.
“We always want more evidence and more trials … but for me, there is enough evidence to treat to target,” says Dr. Singh, who was not involved with the recommendations.
This was the first major consensus paper related to treat to target for gout, and it’s important because gout is often managed by physicians who are not rheumatologists, says Dr. Singh. “This gives attention for treat-to-target to internists, podiatrists and cardiologists.”
But not everyone agrees with Dr. Singh or the expert panel that treat to target should be the standard treatment approach for gout. The American College of Physicians (a national organization of internal medicine physicians) published its own guidelines for gout treatment in November in the Annals of Internal Medicine. In it, the group recommends against starting long-term use of medication to lower uric acid in patients with infrequent flares until more research is available.
Author: Tammy Worth for the Arthritis Foundation