New Guidelines For Gout – Do The Europeans Know More Than We Do Or Not? By Nathan Wei
Gout is a type of arthritis that affects more than 2 million Americans. It is due to an accumulation of uric acid in the blood. Uric acid is a byproduct of purine metabolism. Purines are substances found in certain foods such as red meats, organ meats, shell fish, red wine, beer, and vegetables such as asparagus. When purine containing foods are digested, one of the main substances produced is uric acid. Uric acid accumulates a s crystals and these deposits of uric acid crystals in joints and other organ systems such as the kidneys cause a local inflammatory response and tissue damage.
People who have gout also often have other medical problems such as obesity, high blood pressure, kidney disease, elevated cholesterol, and diabetes.
While rheumatologists in the United States have been trained to deal with gout using U.S. guidelines, the Europeans have recently produced their own set of guidelines that are at least worthy of consideration.
• Confirming suspected gout by documenting the presence of uric acid crystals in the joint fluid of an inflamed joint.
• Evaluating a patient’s risk for gout and also looking at other “co-morbid conditions” (other medical problems).
• Educating a patient about diet, weight loss, and alcohol practices
• Prescribing a drug called colchicine or a non-steroidal anti-inflammatory drug (NSAID) to reduce pain and inflammation.
• Treating acute attacks by removing fluid from an acutely inflamed joint and injecting along-acting glucocorticoid (“cortisone”)
• Prescribing long term therapy with allopurinol. This drug lowers blood uric acid levels by reducing the amount of uric acid produced by purine metabolism.
• Using colchicines or an NSAID during the first few months of allopurinol therapy to reduce the likelihood of gout flares related to the rapid lowering of blood uric acid.
• The treatment goal is to keep the serum uric acid at a level below which uric acid no longer accumulates in joint tissue. The target level is 6 milligrams per deciliter (mg/dL) or less.
These European guidelines are very similar to U.S. guidelines. One major problem that has been discovered is non-compliance by patients. In one survey almost 87 per cent of patients discontinued or interrupted their medication program so that the average length of treatment was only three months. Those patients who had been diagnosed with gout after painful attacks were the ones most likely to be compliant.
Only 3 per cent of patients in this survey received allopurinol doses at a level needed to keep the serum uric acid below 6 milligrams per deciliter. Also, 53 per cent of patients with poor kidney function were prescribed higher than recommended doses of allopurinol. Allopurinol needs to be kept under 300 mgs per day in people with abnormal kidney function in order to reduce the potential for side effects.
Also 83 per cent of patients who were newly diagnosed and started on treatment did not have the appropriate monitoring laboratory tests during the first six months of allopurinol treatment.
Newer drugs in development may make the treatment of gout easier. One big problem has been the toxicity profile of allopurinol. It is a drug that can potentially cause many side effects, including death.
Febuxostat is a drug that is currently in clinical trials.
PEGuricase is another anti-gout therapy that is being studied.
Regardless of therapy though, it is important for patients with gout to seek the opinion of a well-trained experienced rheumatologist.
About the Author: Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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