a cme-certified supplement to rheumatology news

A CME-CErtifiEd SupplEMEnt to

Rheumatology News®

and

This educational supplement is supported by

Original Release Date: August 2013

Most Recent Review Date: August 2013

Expiration Date: August 31, 2015

Estimated Time to Complete Activity: 2.0 hours

Medium or Combination of Media Used: Written Supplement

Method of Physician Participation: Journal Supplement

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Brian F. Mandell, MD, PhD, Facr, MacP, ChairProfessor and Chairman of Academic MedicineDepartment of Rheumatology and Immunologic DiseasesCenter for Vasculitis Care and Research, Cleveland ClinicCleveland, OH

Gout: Demographics, Diagnosis, and Description . . . . . . . . . . . . . . . . . . . . . . . . . . 3Peter a. Simkin, MD, MacrEmeritus Professor of MedicineDivision of RheumatologyUniversity of WashingtonSeattle, WA

Acute Gouty Arthritis: Issues and Recommendations for Prophylaxis and Treatment . . . . . . . . . . . . . . . . . . 4 Michael Pillinger, MDAssociate Professor and Director, Rheumatology NYU Langone Medical CenterNew York, NY

Current Options for Managing Hyperuricemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Brian F. Mandell, MD, PhD, Facr, MacP, Chair

Managing Gout in the Complicated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 N. Lawrence Edwards, MDProfessor of Medicine Division of Clinical Immunology University of Florida Gainesville, FL

Post-Test and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Meeting Clinical Challenges in GoutDiagnostic and Treatment Guidelines for Improved Patient Outcomes

Jointly sponsored by

Copyright © 2013 Global Academy for Medical Education, LLC and Frontline Medical Communications Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher. The Publisher will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.

a cME-cErtiFiED SuPPLEMENt to

Rheumatology News®

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DesiGnationstateMentThe University of Louisville Continuing Medical Education designates this enduring journal supple-ment for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

eDuCationalneeDsEffective therapy for treating symptoms of active gout flares, or gouty arthritis—including colchicine, nonsteroidal anti-inflammatory drugs such as indo-methacin, and oral or injected corticosteroids—have been available for some time, as have medications (the uricosuric agent probenecid and the xanthine oxidase inhibitors allopurinol and febuxostat) that reduce serum uric acid levels, either by increasing uric acid elimination via the kidneys or by reducing the production of uric acid. Febuxostat, a nonpurine analog xanthine oxidase inhibitor, was approved by the US Food and Drug Administration (FDA) in 2009; pegloti-case, a pegylated recombinant uricase for treating chronic gout in patients refractory to conventional therapy, was approved in the United States in 2010. These were the first urate-lowering drugs for gout treatment approved by the FDA in more than 4 decades. Clinical challenges in predicting the course of gout and treating it still exist, although much clarity has emerged as a result of recent clinical trials, and treatment objec-tives for gout and hyperuricemia have been refined. These advances in therapy—along with newer clinical data from interventional studies of traditional medica-tions and more basic research into the underlying disease mechanisms and drug mechanisms of action—are reflected in the first evidence-based guidelines published last year by the American College of Rheumatology (ACR). Clinicians must be familiar with these guidelines and must have an understanding of the studies on which these recommendations are based. This supplement addresses current knowledge about acute gout (gouty arthritis) and hyperuricemia within the context of the ACR guidelines and provides highlights of issues not fully addressed in the 2012 recommendations.

learninGobjeCtivesAt the conclusion of this enduring journal supplement, participants should be able to:• Describetherelationshipbetweenhyperuricemia

and gouty arthritis.• Name the comorbid conditions associated with

hyperuricemia and gouty arthritis and explain why these conditions are linked to elevated serum urate levels and gout attacks.

• Discusstheclinicalandlaboratorycriteriafordiag-nosing acute and chronic gout.

• Implement appropriate therapy to terminate anacute attack of gout.

• Develop and institute individualized treatmentplans for preventing recurrent attacks of gouty arthritis, including lifestyle modification plans, when necessary.

• Explain the options for managing patients withrefractory chronic gout who have failed trials of standard preventive medications.

• Improvestrategies toovercome theobstacles tosuccessful treatment of hyperuricemia in patients with gouty arthritis.

tarGetauDienCeThis educational activity is designed for rheumatologists, internists, primary care physicians, physician assistants, nurse practitioners, and other health care providers who care for patients with gout and hyperuricemia.

DisClosureAs a sponsor accredited by the ACCME, the University of Louisville School of Medicine must ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty par-ticipating in this CME activity were asked to disclose the following:1. Names of proprietary entities producing health

care goods or services—with the exemption of nonprofitorgovernmentorganizationsandnon–health-related companies—with which they or their spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose, we consider the relevant finan-cial relationships of a spouse/partner of which they are aware to be their financial relationships.

2. Describe what they or their spouse/partner received (eg, salary, honorarium).

3. Describe their role.4. No relevant financial relationships.

CMe & PD advisory board Members: Soon Bahrami, MD; Douglas Coldwell, MD, PhD; W. Daniel Cogan, EdD, FAODME; Justin L. Costa, MD; James Creg; Daniel Da Justa, MD; Adair Heyl, PhD; Christopher Jones, MD; Lucy Juett, MS; Gerald Larson, MD; Rana Latif, MD; Kimberly Moore; Karen Napolilli; Lisa J. Pfitzer,MD;ScottPlantz,MD;KerriRemmel,MD,PhD;Michael D. Stillman, MD; Uldis Streips, PhD; Kathy M. Vincent, MD; Lori Wagner, MD; Angela Wetherton, MD; and Stephen Wheeler, MD, have no relevant finan-cial relationships with any commercial interests.

CMereviewer:W.nealroberts,MD, Professor, Chief of Rheumatology, Department of Medicine, University of Louisville.

FaCultyDisClosuresn.lawrenceedwards,MD, has been a consultant for Questcor Pharmaceuticals, Inc. and Swedish Orphan Biovitrum AB.brian F. Mandell, MD, PhD, FaCr, MaCP, has been a consultant for AstraZeneca, Regeneron Pharmaceuticals, Inc., and Savient Pharmaceuticals, Inc. He has also been an editor for Merck Manual. MichaelPillinger,MD, has received grant research support from Takeda Pharmaceutical Company Limited and Savient Pharmaceuticals, Inc.Petera.simkin,MD,MaCr, has received grant research support from Takeda Pharmaceutical Company Limited. He has been an advisory board member for AstraZeneca.joannestill,ba, has no relevant financial relation-ships with any commercial interests.sylviaH.reitman,Mba, and shirleyv.jones,Mba, Global Academy for Medical Education, have no relevant financial relationships with any commercial interests.

aCknoWleDGMentsThe authors would like to thank Global Academy for Medical Education and Joanne Still for assistance with the preparation of this supplement. This activity is supported by an educational grant from Savient Pharmaceuticals, Inc.

universityoFlouisvilleCMe&PDPrivaCyPoliCyAll information provided by course participants is confidential and will not be shared with any other parties for any reason without permission.

This supplement was produced by Global Academy for Medical Education, LLC. Neither the editors of Rheumatology News, nor the Editorial Advisory Board, nor the reporting staff contributed to its content. The opinions expressed in this supplement are those of the faculty and do not necessarily reflect the views of the supporter, the joint sponsors, or the Publisher.

Meeting Clinical Challenges in Gout: Diagnostic and Treatment Guidelines for Improved Patient Outcomes

Original Release Date: August 2013

Most Recent Review Date: August 2013

Expiration Date: August 31, 2015

Estimated Time to Complete Activity: 2.0 hours

Medium or Combination of Media Used: Written Supplement

Method of Physician Participation: Journal Supplement

Hardware/Software Requirements: High-Speed Internet Connection

To get instant CME credits online, go to http:// uofl.me/gout2013. Upon successful completion of the online test and evaluation form, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail. Please add [email protected] to your e-mail “safe” list. If you have any questions or difficulties, please contact the university of louisville school of MedicineContinuing Medical Education (CME & PD) office at [email protected].

jointsPonsorsHiPThis activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the University of Louisville School of Medicine and Global Academy for Medical Education, LLC. The University of Louisville School of Medicine is accred-ited by the ACCME to provide continuing education for physicians.

Epidemiologic surveys over the past 4 decades have demonstrated a substantial increase in the prevalence of gout, with

some reports indicating a doubling between the 1960s and 1990s.1 According to the most recent National Health and Nutrition Examination Survey (NHANES)—NHANES 2007-2008—8.3 million adults in the United States have sought medical attention for gout, a prevalence of 3.9%.2 Men continue to comprise the majority of the patient popula-tion with gout, with a prevalence of 5.9% (6.1 million individuals), compared to a prev-alence among women of 2.0% (2.2 million).2 Most affected women are postmenopausal, and Hak and Choi3 found that their number also has increased.

This increase in prevalence among adults in the United States is not a result of changes in the genetic background of the patient pop-ulation, which has remained essentially constant during this time. Rather, the increase is thought to reflect changes in lifestyle over the past 20 years, especially the increased dietary intake of sugar. Not surprisingly, increasing numbers of patients with gout have comparable increases in such conditions as dia-betes, dysregulation of lipid metabolism, hypertension, and morbid obesity.4-7

Patterns of PresentationThe solubility of urate is reduced at lower tem-peratures, so gout is largely an acral disease, with problems in the hands and feet predomi-nating. Osteoarthritis is another important factor that affects where monosodium urate (MSU) crystal deposition occurs—for example,

MSU crystals preferentially precipitate in the first metatarsal-phalangeal “bunions” of the feet and in the distal interphalangeal “Heberden’s nodes” of osteoarthritic hands. However, increased interest has been paid recently to less common sites of gouty involvement, including the spine and nonarticular tissues in which tophi sometimes occur—the outer ridges of the ear, the skin (especially of the forearm and fingers), cardiac valves, and the kidneys.8

The clinical implications of MSU crystal deposition in the kidneys (gouty nephropa-thy) are not fully understood.9 Clinical studies have found that allopurinol therapy reduces gout attacks and prolongs the lives of patients with gout, but it is not clear whether allopurinol confers a cardiac benefit or a direct renal benefit.

In addition, it now seems that the classic, excruciatingly painful episode of an acute gout attack may have been overstressed. Although such episodes remain important—especially to patients who experience them—clinicians are increasingly recognizing less dramatic episodes. These so-called petit gout attacks have become more evident in individuals whose disease is controlled to the point at which the more strik-ing attacks are less frequent or are eliminated. Petit gout episodes typically last for only a day or so and are not severely painful, particularly when the target sites are nonarticular.

DiagnosisA partial differential diagnosis of gout is listed in the table. The diagnosis commonly is made based on the presence of joint inflamma-tion, a history of previous episodes, elevated

serum uric acid levels, and response to an empiric trial of colchicine. The presence of hyperuricemia (ie, serum urate >7.0 mg/dL) provides useful supporting evidence, but it is important to remember that serum urate levels often fall below this concentration during acute gouty attacks and that not all patients with hyperuricemia experience gout. The detection of crystals in aspirated synovial fluid or tissue from a symptomatic joint in the absence of infection remains the pathogno-monic finding for the definitive diagnosis of gout, but this gold standard test is performed in only about 10% of cases.10

Use of previously published American College of Rheumatology criteria for the in-office diagnosis of gout is associated with misdiagnosis in about 20% of cases.11 Analysis and examination of synovial aspirate is critical to rule out septic arthritis when a patient with no previous history of gout presents with fever and acute monoarticular arthritis. In addition, diagnostic aspirates can be particularly useful in patients with chronic and/or polyarticular

Peter a. Simkin, MD, MacrEmeritus Professor of Medicine, Division of RheumatologyUniversity of Washington, Seattle, WA

Gout: Demographics, Diagnosis, and Description

www.globalacademycme.com/rheumatology•MeetingClinicalChallengesinGout 3

continued on page 11

Meeting Clinical Challenges in Gout

Acute Monoarticular Arthritis•Gout•Septicarthritis•Calciumpyrophosphatedepositiondisease(pseudogout)

•Apatitearthritis•ReactivearthritisChronic and/or Polyarticular Disease•Gout•Seronegativerheumatoidarthritis•Psoriaticarthritis•Osteoarthritis•Septicarthritis(particularlytuberculosisorfungalinfection)

Table. Differential Diagnosis of Arthritis

Gout is an ancient disease, well described by Hippocrates and by many scholars throughout history in both the medical and the lay literature. Acute gouty arthritis is a dramatic event that is commonly seen in the clinical practice (or personal experience) of most physicians and is most certainly seen by all trainees within the specialties of internal medicine. Clinicians have a reasonable understanding of the pathophysiology of

acute gout and hyperuricemia. There are multiple medications available to manage the hyperuricemia as well as the inflammatory components of the disease. Hence, it remains an unexplained paradox why patients with gout, in general, are so poorly managed and thus still suffer the dysfunction and pain of uncontrolled disease.

Different explanations have been offered to try to elucidate the reasons for the inadequate management of this disease. These include patient noncompliance and the multiple comorbidities of those patients with severe gout that make drug choices more difficult, such as drug interactions and distractions due to potentially more morbid disease processes. My own explanation, based on talking with patients and lecturing to primary care physicians and specialists over many years, is that we doctors (1) do not, in fact, fully grasp the true link between progressive gout and a hyperuricemia level exceeding 6.7 mg/dL, (2) do not appreciate the relationship between changes in serum urate levels and the provocation of acute attacks, and (3) do not adequately emphasize to our patients the need for long-term (as well as intermittent acute) therapy.

The recently published American College of Rheumatology guidelines for the management of gout, although lengthy and complex in places, provide a conceptual scaffold to assist in the management of patients with gout. In this educational supplement, the faculty hopes to enhance your understanding of the pathogenesis of gout and link that understanding to therapeutic decision making, but, most importantly, to present practical approaches to facilitate the management of patients with hyperuricemia and acute gout, including those with significant medical comorbidities.

Brian F. Mandell, MD, PhD, Facr, MacP, Chair

By definition, gout is a disorder in which abnormalities of purine metabolism and/or renal function result in fluctuat-

ing but persistently elevated serum and interstitial concentrations of urate (hyperuri-cemia). Because these concentrations exceed the urate saturation point (approximately 6.8 mg/dL), the eventual result is the precipi-tation of monosodium urate (MSU) crystals in and around joints and other tissue. Acute gouty arthritis attacks (commonly referred to as acute gout) occur when MSU crystals—either precipitating spontaneously or upon mobilization from predeposited tissue stores—trigger a complex and explosive inflammatory response. Some individuals may experience one or a few attacks of acute gouty arthritis over a lifetime; others have a more chronic course, characterized by multi-ple, frequent attacks.

Based on this physiologic understanding, therapeutic interventions for gout must target one or more of the three stages of the disease: the metabolic processes involved in hyperurice-mia (to reduce the conditions permitting attacks), the formation of MSU crystals (a target not yet therapeutically employed), and/or the inflammatory response to the presence of those crystals (to abrogate or prevent acute gouty arthritis attacks). In this article, the current options for managing acute gouty arthritis attacks are addressed, including the recommen-dations made in the first American College of Rheumatology (ACR) guidelines for gout.1,2

Pathogenesis of Acute Gout A gout attack occurs when MSU crystals trigger an acute inflammatory reaction, leading to the four cardinal signs of inflam-mation: heat, redness, swelling, and pain. The exact cause of a gout flare in an individual patient often is not identified. However, known triggers include joint trauma (mobi-lizing preformed crystals), overuse of alcohol or purine-rich foods (promoting hyperurice-mia by metabolic mechanisms), and surgery and infection (metabolic stress, fluid shifts, and acidosis). Not surprisingly, all of these are associated with an acute inf lammatory response at some site, most commonly in a joint. Paradoxically, the acute reduction of serum uric acid—pharmacologically or by other means—also promotes acute attacks, apparently as a result of sloughing of crystals from preexisting deposits during the urate dissolution process.

The mechanisms through which MSU crystals drive inflammation are complex. An often overlooked mechanism is one that was first described in the 1970s, involving the complement system.3 MSU crystals activate complement on their surfaces through several distinct mechanisms, resulting in the release of C3a and C5a (anaphylotoxins). These highly inflammatory proteins then disperse in a gradient, activating intravascu-lar neutrophils and attracting them up a chemical gradient.3,4 Although the role of neutrophils in gout is appreciated by most practitioners, fewer are aware of our increas-ing understanding that tissue macrophages also play a critical role in gout.

The tissue macrophage is a phagocytic leu-kocyte with the likely function of immune surveillance. Malawista et al5 demonstrated that MSU crystals are highly effective activa-tors of macrophages. Macrophages produce cytokines that activate the vascular endothe-lium, as well as neutrophils in the blood vessels themselves.

The underlying mechanism for how mac-rophages do this has been described within the last decade by Martinon and colleagues,6 who showed that uric acid crystals have the ability to activate the inflammasome, a mul-timolecular complex in macrophages and other leukocytes that can lead to the activa-tion and the secretion of interleukin 1 (IL-1). These seminal studies by Martinon et al6 indicate that other cytokines produced by leukocytes actually are secondary to IL-1—that is, when secreted, IL-1 acts on the macrophages to cause them to make still more cytokines. These cytokines then act both on intravascular neutrophils and on the vascular endothelium past which the neutro-phils are flowing, to drive neutrophils to first adhere to the vessel wall and subsequently to exit into the tissue, where the complement gradient drives them toward the crystal trigger. The final event in the cascade occurs when the neutrophils phagocytose the crys-tals, resulting in the production of additional cytokines and inf lammatory and tissue-destroying enzymes.

There is some evidence that if the number of macrophages is depleted or their ability to respond is inhibited, a gout attack will not occur. Thus, macrophages, perhaps along with complement products, are responsible for ini-tiating an attack of acute gout.

Treatment Recommendations in the ACR Guidelines Because the acute attack is an inflammatory process, management of an individual attack should focus on treating the inflammation rather than altering the level of serum urate. For mild to moderate attacks (for example, one or just a few small joints or one or two large joints), monotherapy with an anti-inflammatory agent is recommended. For a severe polyarticular f lare, combination therapy with two anti-inflammatory drugs may be considered. After responding to treat-ment, patients may proceed to a chronic management regimen.2

If standard anti-inflammatory treatment fails to bring an acute gout attack under control—and presuming the possibility of a misdiagnosis has been eliminated—a different anti-inflammatory agent or combination therapy with more than one agent may be tried. If the response is still inadequate after this second step, the guidelines recommend consid-ering use of “off-label therapy” (such as IL-1– directed therapy).2

Standard Anti-Inflammatory Medications for Acute GoutAt present, the roster of anti-inflammatory medications used in acute gout include colchi-cine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids.

colchicine. The oldest drug used to treat gout, colchicine, and has been in use intermit-tently for more than 2 millennia. Colchicine works by inhibiting the ability of cells to manage microtubular function. For reasons that are unclear, cells of the myeloid lineage may be particularly susceptible—specifically, macrophages and neutrophils, the key players in acute gouty inflammation, as noted above. In addition, colchicine also has been shown to have effects on vascular endothelial cells, making them less adhesive for leukocytes such as macrophages and neutrophils and inhibiting the ability of these cells to migrate to a site of inflammation.

At excessive doses, colchicine’s microtubule-disrupting effects result in gastrointestinal intolerance, neuropathy, myopathy, and other signs of toxicity. At therapeutic doses, colchi-cine is relatively specific for inflammatory and endothelial cells and, therefore, is particu-larly effective in diseases that involve those

Michael Pillinger, MD Associate Professor and Director, Rheumatology NYU Langone Medical Center, New York, NY

Acute Gouty Arthritis: Issues and Recommendations for Prophylaxis and Treatment


cells. Recently, it has been shown that the administration of colchicine may inhibit the action of inflammasome and the production of IL-1 in macrophages.6

Colchicine should be used at relatively low doses, even for acute attacks, and seems most effective when treatment is started early after the start of an acute gout attack—ideally, within the first 24 to 36 hours after the onset of symptoms.

NSaiDs. Because it was the first in its class to be introduced and used to treat acute gout, indomethacin tends to be the NSAID of choice for many clinicians. However, all NSAIDs, when used in sufficient doses, are effective for managing acute gout, and some of these have better side effect profiles than indomethacin in selected patients.

All of the agents in the NSAID class work by inhibiting cyclooxygenase (COX) and block- ing the production of the proinflammatory molecule prostaglandin E2. COX-2–selective NSAIDs are less well studied in acute gout than the other NSAIDs but seem to be equally effec-tive when used in high doses. These agents may have reduced gastrointestinal toxicities than those of the traditional NSAIDs and they do not affect platelet function, but the risk for adverse effects on renal function is no better than that with other NSAIDs.

When started early and used at high doses, NSAIDs are effective in managing the inflam-mation in acute gout and have the added advantage of an analgesic effect.

corticosteroids. Oral prednisone is the traditional choice for corticosteroid therapy in acute gout. However, methylprednisolone, dexamethasone, or another corticosteroid are other effective options, and intravenous or intra-articular routes of administration may be indicated in selected cases.

The mechanisms of action of corticosteroids are complex. When these molecules are taken into inflammatory cells, they bind to cytoplas-mic receptors and translocate to the nucleus where they interact with specific DNA-binding sites. Corticosteroid molecules either block the ability of other proteins to stimulate transcrip-tion of inflammatory molecules (such as nuclear factor-kappa B) or stimulate the cell’s genes to produce anti-inflammatory molecules (such as annexin 1 or lipocortin).

The dosage of oral corticosteroids for acute gout should typically be in the range of 20 to 30 mg/day until the desired response is achieved. The drug can then be tapered over a period of 7 to 10 days or continued for 5 to 7 days and, if a complete response is achieved, stopped without tapering.

Alternate and Emerging Therapies for Acute Goutadrenocorticotropic Hormone (actH). ACTH, once widely available and used in the United States for a variety of clinical indica-tions, currently has orphan-drug status and an indication for use in pediatric patients with

infantile spasms. As a stimulator of cortisol production in the adrenal glands, ACTH has potent anti-inflammatory effects and once was used commonly to treat gout flares. Recent studies suggest that ACTH also works by binding to melanocyte-stimulating hormone receptor type 3, an additional anti-inflamma-tory mechanism of action independent of adrenal gland stimulation.7

Although ACTH currently is produced in small quantities and is extremely costly, the 2012 ACR guidelines mention this agent as an option in selected patients.2

iL-1–Directed treatments. The work of Martinon and colleagues6 that led to the understanding of the role of IL-1 in acute gout flares was directly responsible for the study and use of IL-1 inhibitors in gout within the past 10 years.

Anakinra, an IL-1 receptor antagonist approved for use in rheumatoid arthritis, was the first to be tried for gout. Its off-label use was supported by the results of a small open-label study in 10 patients with gouty flares who could not tolerate or who failed therapy with the standard gout treatments.8 To date, no placebo-controlled or comparator- controlled trials have been published, but anecdotal evidence is accumulating regarding the efficacy of this biologic agent in gout.

Two other IL-1–targeted medications cur-rently being used are rilonacept (also known as IL-1 Trap) and canakinumab. Unlike anakinra, these agents are not IL-1 receptor antagonists. Rilonacept engineers two IL-1 receptors and attaches them to the Fc portion (or tail end) of an immunoglobulin. The resultant molecule has the ability to “trap” IL-1, which is then cleared from the circulation. Rilonacept has been studied with indomethacin as a compara-tor in a superiority trial. In these trials, rilonacept was effective in acute gout but was not superior to indomethacin.9

Canakinumab, which currently has provi-sional approval in Europe for the treatment of gout, is an IL-1 monoclonal antibody. Canakinumab was studied in patients with acute gout in a comparison trial against triamcinolone injection. Canakinumab demonstrated superior efficacy in this trial.10

Both rilonacept and canakinumab currently have orphan-drug status for use in children with neonatal-onset multisystem inflamma-tory disease, a life-threatening disease caused by excess circulating IL-1.

Recommended Urate- Lowering StrategyFor the chronic management of most patients with gout, lowering of serum urate levels is recommended. Reducing urate to a level less than 6.0 mg/dL (or lower) prevents the forma-tion of new crystals, permits the resorption of established deposits, and eventually should result in complete abolition of gouty attacks.1

Initiating Therapyallopurinol. The dosage of allopurinol that many clinicians have used in the past to initi-ate therapy is 300 mg/day. However, the ACR guidelines now recommend starting at 100 mg/day and titrating up about every 2 to 5 weeks to a level sufficient to lower serum urate levels to less than 6.0 mg/dL. There are two reasons for this new recommendation. First, allopurinol rarely can cause a severe allergic-type hypersensitivity reaction, which can even be fatal, and the data are confusing about whether that is dose dependent. Because of the uncer-tainty and based on the accumulated evidence reviewed by the guidelines committee (includ-ing a recent study by Dalbeth et al11), a more cautious approach seems prudent. The second reason to start allopurinol at a low dose and slowly and regularly titrate upward is that this approach may reduce the likelihood of pro-voking acute gout attacks as the serum uric acid levels fall toward the target range (see below). The maximum approved dose is 800 mg/dL; the dose should be titrated to the target urate level, in much the same way that the correct dose of antihypertensive medication is the dose needed to control the blood pressure.

Febuxostat. Like allopurinol, febuxostat is a xanthine oxidase inhibitor. The recom-mended starting dosage of febuxostat is 40 mg/day, increasing after several weeks to 80 mg/day if needed to achieve the target serum urate level. In Europe, but not the United States, a 120-mg dose is approved and may be effective in otherwise recalcitrant cases.

Pegloticase is a rapid-acting, potent urate-lowering agent, approved by the US Food and Drug Administration for patients with gout refractory to conventional treatment. In con-trast to the other agents, pegloticase is a uricase enzyme that acts to digest serum urate directly and so lower the total body urate burden. Pegloticase is administered intravenously on an every 2-week schedule and has the potential to dramatically lower serum urate levels. Like the other urate-lowering drugs, its use is associated with an increased risk for acute gout attacks. Unfortunately, many patients develop antibod-ies to pegloticase, causing loss of efficacy.

When to Initiate TherapyDuring an acute attack, a patient who is already on urate-lowering therapy should continue this treatment without any changes in dosage. If a patient is not on urate-lowering medication, it has been widespread practice not to start use of urate-lowering drugs until the acute flare is over and the patient is stable, because urate lowering may theoretically worsen the acute attack. However, the 2012 ACR guidelines recommend that another strategy may also be acceptable: A urate-lowering drug may be started during an acute attack provided the acute inflamma-tion has been adequately managed.



H yperuricemia is the root cause of gouty arthritis, or acute symptomatic gout. In some individuals, circulating levels

of urate persistently exceed the threshold above which monosodium urate (MSU) deposits form in and around joints and other tissues (Figures 1 and 2). This threshold, or saturation point, has been identified as approximately 6.7 to 6.8 mg/dL. Effective long-term management of gout requires lower-ing the serum urate levels to—and maintaining levels below—this saturation point. This article addresses the strategies currently rec-ommended for achieving and maintaining recommended target levels of serum urate and discusses these within the context of the American College of Rheumatology’s first published guidelines on gout.1

Causes of HyperuricemiaHumans and some other primate species have a genetic absence of uricase. In most other animals, this enzyme converts uric acid to allantoin, which is more easily excreted by the kidney; thus, in humans, the serum urate level is much higher than in most other species.

It has been suggested that, early in human evolution, the loss of uricase contributed to higher serum levels of urate that promoted increases in blood pressure necessary in the evolution to an upright posture. Additionally, humans developed potent renal mechanisms to retain, rather than efficiently eliminate, uric acid. In the human kidney, most of the uric acid is reabsorbed in the proximal renal tubule, predominantly by the urate trans-porter URAT-1.

The currently recommended target of serum urate in patients with known gouty arthritis, in whom the decision is made to use hypouricemic therapy, is below 6 mg/dL. This also was the target level used to deter-mine hypouricemic efficacy in clinical trials. At present, there are insufficient outcome data to support lowering the serum urate level in patients without gouty arthri-tis, although this may change in the near future as accumulating data increasingly support the concept that uric acid may con-tribute directly to the development or progression of chronic kidney disease, hypertension, and other components of the metabolic syndrome.

Pharmacologic TherapyUricosuric TreatmentProbenecid, approved for treating hyperurice-mia in patients with gout, lowers serum uric acid by increasing its excretion by the kidney, via inhibition of URAT-1. Other agents—for example, the angiotensin II receptor antago-nist losartan, approved for hypertension—are not specifically antihyperuricemics but are known to have uricosuric effects. Another uricosuric agent currently in development is a highly potent inhibitor of URAT-1. In early clinical trials, this URAT-1 inhibitor seems to be extremely effective at lowering serum urate levels, particularly when used in combi-nation with a xanthine oxidase inhibitor.

Xanthine Oxidase Inhibitors Most of the circulating urate is produced as a cellular metabolic by-product. The most fre-quently used pharmacologic approach to lowering serum urate levels is to decrease the synthesis of uric acid by inhibiting xanthine oxidase. The first xanthine oxidase inhibitor developed was allopurinol, which is still a mainstay of antihyperuricemic therapy. This agent is cost-effective and clinically effica-cious when dosed appropriately.2

In 2009, febuxostat was introduced, the first new treatment for hyperuricemia to be

developed in many decades. In clinical trials, 80 mg/day of febuxostat was shown to be superior to 300 mg/day of allopurinol.3,4 However, it is imperative to note that the clinical trial protocols for these studies did not permit dosages of allopurinol higher than 300 mg/day. In routine clinical practice, clini-cians should exceed this artificial 300-mg/day threshold of allopurinol, titrating upward as needed to achieve the target urate level. No clinical trials have yet been done comparing the maximum approved febuxostat dosage of 80 mg/day with appropriately dosed allo-purinol. As discussed elsewhere in this series, even in the setting of chronic kidney disease, the allopurinol dose can usually be success-fully increased to an effective dose.

Like allopurinol, febuxostat inhibits xan-thine oxidase but has a different chemical structure. The newer drug is uniquely valuable in patients who cannot tolerate or who have hypersensitivity or other allergic reactions to allopurinol.

UricaseAll patients with gout have tophi, deposited as uric acid around the joints, although these may not be clinically detected by routine examina-tion or imaging. However, some patients have macrotophaceous gout, with deposits so large that they are palpable or visible under the skin.

Brian F. Mandell, MD, PhD, Facr, MacPProfessor and Chairman of Academic Medicine, Department of Rheumatology and Immunologic DiseasesCenter for Vasculitis Care and Research, Cleveland Clinic, Cleveland, OH

Current Options for Managing Hyperuricemia


Figure 1. ChronicGoutThis68-year-oldman,whohadneverbeentreatedforgout,complainedofchronicstiffness(slightlyworseinthe morning) and loss of finger mobility, but no pain. The diagnosis of chronic gout was confirmed ondemonstrationofsodiumuratecrystalsaspiratedfromaswollenjoint.

ReprintedwithpermissionfromMandellBF.Theclinicalpicture:Thecrystal,thegout,andtheparadox.Cleve Clin J Med.2002;69:720. Copyright©2002TheClevelandClinicFoundation.Allrightsreserved.


In these patients, in particular, resolution of the uric acid burden could take many years with traditional therapy. Other patients may not tolerate or appropriately respond suffi-ciently to either or both uricosuric or xanthine oxidase inhibitors. Pegloticase is a novel and relatively recent alternative therapeutic option.

Pegloticase is approved by the US Food and Drug Administration for the treatment of gout in patients in whom conventional therapy has been used, but whose serum urate level has not normalized and who still have signs and symp-toms of gout. In addition, pegloticase is indicated for patients for whom the conventional gout-treatment drugs are contraindicated.5

Pegloticase is synthesized uricase with a polyethylene glycol (PEG) coating designed to decrease the immunogenicity of the com-pound and increase the drug’s half-life. Pegloticase, administered intravenously at 2-week intervals, is extremely effective at low-ering serum urate levels—in some cases, to less than 1 mg/dL—very rapidly. Treatment must continue until the urate deposits dissolve; in some patients, visible and palpable tophi are dissolved in a few months, but in others dis-solution of tophi may take more than a year.6

Because the level of urate decreases so rapidly with pegloticase, acute gout attacks—some-times severe—are common. For this reason, anti-inflammatory therapy must be given con-currently with pegloticase treatments.

Despite the PEG coating, approximately 50% of patients develop antibodies to pegloti-case.5 Some develop high levels of antibodies, reducing the efficacy of the drug, sometimes significantly. A proportion of patients who develop antibodies to pegloticase will experi-ence allergic reactions. Because the lack of a serum urate level response to the drug corre-lates with antibody formation, loss of efficacy, and allergic reactions, serum urate levels should

be monitored carefully (prior to each infu-sion) in patients receiving pegloticase. Patients who initially respond minimally or do not respond at all may have preexisting antibodies to the pegylated portion of the pegloticase molecule. This unexplained phenomenon has been seen even in patients who have not previ-ously received a pegylated drug compound. Approaches to decrease the immunogenicity of pegloticase currently are being studied.

When and How to Use Urate-Lowering TherapyWhen the decision is made to lower the serum urate level in order to decrease the burden of uric acid deposition, as part of the long-term treatment plan for a patient with gout, the goal is to maintain the serum urate levels at the point at which MSU deposits are depleted—that is, well below the uric acid saturation point of about 6.7 mg/dL. Because this process can take many years, the treat-ment of hyperuricemia is long-term.

The choice of agent, dosage, and timing of initiation of therapy must be individual-ized. For example, hyperuricemia in the absence of a history of gout attacks currently is not an indication for therapy; not all patients who have hyperuricemia will develop gout (Figure 3). The experience of a single gout attack or even multiple attacks also may not prompt initiation of treatment for hyper-uricemia in patients at a very advanced age or perhaps with life-shortening comorbidities. Alternatively, in a young patient with a high urate level and a family history of severe tophaceous gout, a single attack may justify therapy because of the high likelihood that such a patient will experience severe gout in the future. As another example, a patient with immunoglobulin A nephropathy—who is likely to need kidney transplantation in the future—would also be a candidate for urate-lowering therapy after a single attack; in a case such as this, the risk is high that the patient would develop chronic severe gout posttransplantation because of the likely necessity for prescribing calcineurin antago-nists (agents that increase the likelihood of severe gout).

Once the decision has been made to treat with a urate-lowering agent, a target serum urate level should be established. The 2012 American College of Rheumatology guidelines for gout recommend a target of 6 mg/dL, although European League Against Rheumatism and other European guidelines recommend targets even lower than this. Perez-Ruiz and colleagues7 demonstrated a number of years ago that the lower the circu-lating urate level is, the more rapidly the body dissolves tophi and urate deposits.

Studies of urate-lowering treatments also have demonstrated that sudden decreases in urate are associated with an increased risk for

acute gout attacks, regardless of the urate-low-ering medication used.4 This increased frequency of gout attacks after initiating urate-lowering therapy seems most marked within a month or so of starting the therapy but may persist for a year or more.

Using allopurinol as an example, a reason-able approach is to initiate therapy at 50 mg once daily, increasing the dosage every 1 to 2 weeks, while monitoring the serum urate level, until the target is reached or until the patient no longer tolerates the drug. A low starting dose also is safer from the standpoint of hypersensitivity reactions, as these rare reactions seem even less likely to occur if the drug is started at a low dose.8

It has been a long-held maxim that urate-lowering therapy should not be started during an acute attack of gout, although this practice has been the subject of recent discussion. Taylor et al9 demonstrated in a small study that urate-lowering therapy can be started even during an acute attack of gout, provided effective anti-inflammatory therapy is used simultaneously. (For additional discussion, see Dr Pillinger’s article on page 4.)

Role of Dietary/Lifestyle Changes in Managing HyperuricemiaDietary modifications alone have been largely unsuccessful in changing the disease process. Likely because most of the urate in serum is derived from cellular metabolism and not dietary intake of purines, rigid dietary restrictions involving avoidance of purine-rich foods are not sufficient to reduce serum urate levels to below 6 mg/dL in most patients with hyperuricemia. However, recent research suggests that ingestion of certain sugars is an extremely important and modifiable contributor to hyperuricemia leading to gout. Sugars—primarily fructose contained in the high-fructose corn syrup in soft drinks, sports drinks, and some other foods—cause an increased synthesis of purines and increased urate levels.10-12

Figure 2. Intradermal TophusThis photo shows an intradermal tophus ofthe thumb in a 68-year-old patient withchronic gout. The patient had tophi on thepadsofotherfingersaswell.


ReprintedwithpermissionfromMandellBF.Theclinicalpicture:Thecrystal,thegout,andtheparadox.Cleve Clin J Med.2002;69:720.Copyright©2002TheClevelandClinicFoundation.Allrightsreserved.

Figure 3. Aspirated “Urate Milk”Fluidaspiratedfromtheolec-ranon bursa of a 42-year-oldman showed sheets of uratecrystals, a small number ofleukocytes(60%neutrophils),andnolipidcrystals.Theareawasdistendedbutnotpainful.Hehadneverbeendiagnosedwith gout, but it is likely thatpreviousepisodesofjointpain(described by the patient aspainful bunions and “twistedankles”) actually were goutyarthritisattacks.ReprintedwithpermissionfromMandellBF.Theclinicalpicture:Thecrystal,thegout,andtheparadox.Cleve Clin J Med.2002;69:720.Copyright©2002TheClevelandClinicFoundation.Allrightsreserved.

M any patients with gout have comor-bid medical conditions, often limiting the utility of standard anti-

hyperuricemic and anti-inf lammatory medication regimens. Others with comorbid conditions are at risk for drug-drug interac-tions; either they are taking medications that interfere with antigout agents or the antigout medications interact with drugs for comorbid conditions. In addition, some patients are considered complicated because they are refrac-tory to therapy or are unable to tolerate the standard forms of gout treatment. Finally, certain environments—especially hospitals—are problematic for some patients with gout, resulting in complications. This article provides an overview and update on the man-agement of patients with some of the more commonly encountered complications.

Gout Treatment and ComorbiditiesIt has been long recognized that gout is associ-ated with a number of other medical and metabolic conditions, such as chronic kidney disease (CKD), cardiovascular disease (CVD), hypertension and lipid abnormalities, type 2 diabetes, obesity, and the metabolic syn-drome. The frequency of these in patients with gout varies from study to study, but at least one of these is seen in 20% to 50% of the patient population with gout.1

Chronic Kidney DiseaseThe standard drugs used for urate-lowering therapy, including allopurinol and probene-cid, historically have been problematic in patients with CKD. For the last 25 years, both published reports and the general experience of clinicians who treat patients with gout suggest that allopurinol dosages should be lower in patients with CKD. However, within the past 5 years, it has been clearly demon-strated that lower dosages are important for initiating therapy, but subsequent dosages need not be limited by renal dysfunction. Allopurinol can be safely titrated upward in these patients to treat to the target serum urate level.2

The xanthine oxidase inhibitor febuxostat has the advantage of not being eliminated in its active form by the kidney and, therefore, may be a more appropriate choice in patients with CKD in whom allopurinol is not tolerated.

In patients with significant CKD in whom the glomerular filtration rate is below 50 mL/min, currently available uricosuric drugs such as probenecid are ineffective.3

In treating the pain of acute gout, medica-tions such as nonsteroidal anti-inflammatory drugs (NSAIDs) may have limited use in patients with CKD or in patients in whom the added burden of fluid retention would worsen heart failure.

Colchicine dosing also needs to be limited in patients with CKD. Patients with stage III CKD or worse should take no more than one tablet daily, and those with glomerular filtra-tion rates less than 20 mL/min should take no more than one tablet every other day. Colchicine also has several contraindications when administered with other commonly used medications. Corticosteroids, either orally or parenterally administered, may worsen under-lying medical conditions in patients with significant heart disease or diabetes.

Cardiovascular DiseaseCVD has long been recognized as a comorbid medical condition associated with gout. Some evidence now exists supporting the possibility that elevated serum uric acid levels may have a role in the etiology of CVD.4 A more established association between the two conditions is the increased level of circulating inflammatory proteins such as cytokines that produce chronic inflammation in the joints (predisposing to gout) and also contribute to atherosclerosis.4 Unfortunately, anti-inflammatory therapy—especially NSAIDs and corticosteroids—often are problematic in patients with gout who also have CVD.

In patients with severe CVD, the experi-ence of acute gout pain represents stress that can worsen angina and even precipitate myo-cardial infarction.

Hypertension and Lipid AbnormalitiesIn patients with hypertension, any diuretic medication can be expected to elevate serum urate levels because diuretics increase the reabsorption of uric acid in the renal proximal tubules, increasing the risk for both hyperuri-cemia and gout.5,6

In addition, beta-blockers and angiotensin II receptor blockers (ARBs) other than losartan have been shown to increase the risk for gout.7 However, one ARB, losartan, has been shown to have unique uricosuric properties and, thus,

may be used therapeutically to benefit both hypertension and gout.

Similarly, in patients with hypertriglyceri-demia, niacin promotes uric acid retention, whereas fenofibrate has uricosuric effects.

Intolerance or Resistance to Gout TherapyAs many as 10% to 15% of patients with gout are refractory or intolerant to the stan-dard urate-lowering drugs allopurinol and probenecid.8

It is important to note that some patients who have been determined to be refractory to allopurinol probably have been underdosed. For example, it is commonly recognized that the majority of patients with gout will not achieve a serum urate level of less than 6 mg/dL on 300 mg/day of allopurinol, the standard dosage. Although allopurinol is approved by the US Food and Drug Administration (FDA) for dosing up to 800 mg/day, studies have dem-onstrated that fewer than 3% of all prescriptions written for allopurinol in the United States are for dosing above 300 mg/day.9 Thus, the per-ceived inadequacy of allopurinol in some patients actually should be reconsidered in light of these observations.

True intolerance to allopurinol is unusual, with an estimated prevalence of 5%.10 The most frequent manifestations of allopurinol intolerance are gastrointestinal symptoms and benign rashes.

A rare, true hypersensitivity reaction occurs in about 1 to 3 per 1,000 patients who start therapy with allopurinol.2 It is now known that individuals who are prone to such reac-tions have a genetic predilection (HLA-B*5801 positive), seen primarily in persons of Han Chinese, Southeast Asian, and South Pacific Islander ancestry; presumably other markers exist for other populations. Stamp and col-leagues2 have demonstrated that the risk for allopurinol hypersensitivity syndrome mani-festing in susceptible individuals is higher if the drug is started at 300 mg or higher.

This evidence prompted the inclusion of a recommendation in the 2012 American College of Rheumatology gout guidelines that the initial dosage of allopurinol should be limited to a maximum of 100 mg/day. In patients with stage IV or V CKD, the initial dosage of allopurinol should be even lower, 50 mg/day.11

N. Lawrence Edwards, MDProfessor of Medicine, Division of Clinical Immunology University of Florida, Gainesville, FL

Managing Gout in the Complicated Patient


Goutisa“numbersgame.”Patientswithgoutshouldknowtheirtargetand their most current uric acidlevels,justasindividualswithdiabe-tesneedtoknowwhattheirbloodglucose levels are and should be,and patients with hypertensionneedtomonitorandmaintaintheirbloodpressuretarget.

Flarescanhappenevenwhentheserum uric acid level is normalbecausegout is a disease of urate burden.Theserumuricacidlevelmeasuresonlythecirculatinguricacid;thetotalpoolofurateinthetissues may be quite large evenafter the serum level has beenloweredwiththerapy.

The treatment goal for an acute gouty arthritis attack is to control inflammation and alleviate pain. Colchicine, NSAIDs, corticoste-roids, and possibly other anti- inflammatory medications areusedforsymptomaticrelief.

The ultimate treatment goal for gout is to lower serum uric acid levels in the long term. The target levelforallpatientswithgoutisbelow6.0mg/dL;insomepatientswith more advanced disease, this target may be even lower.The medications currently approved to lowerserumuricacidlevelsareallopurinol,probenecid,febuxostat, and—in certainpatients—pegloticase.

Expect flares to increase and be more severe when treatment for hyperuricemia begins. Anti-inflammatorytherapyshouldalwaysbestartedfirst;thiswillhelp manage pain until the diseaseisundercontrol.

Nonadherence in patientswith goutleads topoorcontrolof thedisease.Thisoftencanbeattributedto inad-equatepatienteducationbythehealthcare provider. In fact, the 2012American College of Rheumatologyguidelines on gout11 stress that lack ofeffectivepatienteducationcontrib-utes to treatment failure, prolongedsuffering,andpossiblejointdestruc-tion.Thefollowingfivetalkingpointsareofferedasaquickguidetocover-ing the most important issues for patientstounderstand.

5.

For patients who are unable to use either of the standard urate-lowering medications, in whom these medications have not yielded sat-isfactory clinical results, and who have severe macrotophaceous gout, the pegylated uricase drug pegloticase should be considered. (For further discussion of pegloticase treatment, see Dr Mandell’s article on page 6.)

Gout and Special EnvironmentsPatients who are fasting because of planned surgery or who have even mild lactic acidosis postoperatively may experience an acute gout attack because of associated fluctuations in uric acid.

In addition, hospitalized patients on dialy-sis who experience a gout attack are difficult to manage because neither colchicine nor NSAIDs are good options in this setting. Oral or parenteral glucocorticoids often are used in such patients; however, in patients with dia-betes, these medications will likely worsen their already unstable diabetes. In such cases, the interleukin 1–directed therapies anakinra and canakinumab may provide some relief but are not currently approved by the FDA for this purpose.

None of the currently available urate-lowering therapies is approved for patients on dialysis. However, among these, febuxostat is better tolerated in people with diminished renal function. Newer investigational uricosuric agents show promise for treating such patients.

A common problem for patients with gout—especially for those who have been sta-bilized on urate-lowering medications—is that medications are often discontinued on hospi-tal admission. When urate-lowering drugs are stopped for longer than even a few days, the resulting sudden increase in serum urate levels will likely trigger an acute gout flare.

Gout in Organ Transplant RecipientsIt has been long recognized that patients taking cyclosporine or tacrolimus following organ transplantation have an unusually accelerated form of gout, sometimes referred to as “organ transplant gout.” These immuno-suppressants interfere with the uric acid transport mechanisms in the proximal convo-luted tubule of the kidney, essentially preventing its excretion in the urine.

Instead of the typical course of develop-ment involving a number of years or decades, this aggressive form of gout can develop in as little as 1 or 2 years, manifesting with tophi, joint destruction, and marked elevations in serum urate levels.12 To bring the serum urate levels under control, an aggressive regimen of urate-lowering therapy is required.

In addition, patients with organ trans-plant gout typically experience frequent and extremely painful gout f lares. Standard

monotherapy regimens of colchicine and NSAIDs often are inadequate to manage the inflammation of an acute f lare in these patients. Long-term combination anti-inflammatory therapy may be required with both colchicine and an NSAID, possibly along with low-dose corticosteroid therapy.

Young Patients With GoutIndividuals under age 25 who develop gout represent a complicated patient population. Most have a genetic predilection for hyperuri-cemia and gout and often have a more aggressive form of the disease, characterized by earlier formation of tophi and renal calculi.

Patients With Advanced GoutPatients with advanced gout are usually those in whom the gouty symptoms were over-looked or misdiagnosed during the earlier stages of gout. This group also includes those who have been chronically undertreated with urate-lowering therapies. These patients have a destructive and often crippling form of arthritis associated with large tophi and con-siderable functional limitation.

Patients with advanced gout are difficult to treat because of the heavy urate burden they carry and because they are frustrated by previous failed attempts to reduce the size or number of tophi and the painful clinical consequences of that treatment failure.

Pegloticase, approved by the FDA for such patients, can produce a rapid response in about 50% of cases.13 Within the first week of therapy, serum urate levels decrease to well below the standard target level of 6 mg/dL and, generally, to below 1 mg/dL. Such low levels of serum urate result in greatly enhanced resorption of urate deposits stored around joints and other tissues throughout the body.14 Patients who can tolerate pegloti-case infusions (given intravenously as 4 mg every 2 weeks) and who respond to it usually see marked improvement over relatively short periods of time. Even very large tophi can show dramatic resolution in as little as 3 to 6 months, improving functional ability and, therefore, quality of life.14

Patients must understand that the thera-peutic trade-off for this benefit is the greatly increased risk for gout flares that can be frequent and severe without appropriate anti-inflammatory prophylaxis.

SummaryComorbid conditions are common in patients with gout, particularly CKD, CVD, and hypertension. The standard anti-inflammatory and urate-lowering treatments for gout are problematic in many of these patients. Because of the frequency of these comorbid medical conditions, many patients with gout undergo frequent admissions to hospitals, require dialy-sis, or may even need organ transplantation.

Top Five Talking Points for Patient Education


1.

2.

3.

4.

All of these scenarios require some imaginative thinking when it comes to managing gout. Newer drugs currently in the research pipeline and existing drugs approved for other indica-tions are being studied and used to treat gout in these patient populations, and offer useful alternatives to the standard treatments. n

References1. Vázquez-Mellado J, García CG, Vázquez SC, et al.

Metabolic syndrome and ischemic heart disease in gout. J Clin Rheumatol. 2004;10:105-109.

2. Stamp LK, Taylor WJ, Jones PB, et al. Starting dose is a risk factor for allopurinol hypersensitivity syn-drome: A proposed safe starting dose of allopurinol. Arthritis Rheum. 2012;64:2529-2536.

3. Schlesinger N. Management of acute and chronic gouty arthritis: Present state-of-the-art. Drugs. 2004;64:2399-2416.

4. Feig DI, Kang DH, Johnson RJ. Uric acid and cardio-vascular risk. N Engl J Med. 2008;359:1811-1821.

5. Choi HK, Atkinson K, Karlson EW, Curhan G. Obesity, weight change, hypertension, diuretic use, and risk of gout in men: The Health Professionals Follow-Up Study. Arch Intern Med. 2005;165: 742-748.

6. Reyes AJ. Cardiovascular drugs and serum uric acid. Cardiovasc Drugs Ther. 2003;17:397-414.

7. Choi HK, Soriano LC, Zhang Y, Rodriguez LA. Antihypertensive drugs and risk of incident gout among patients with hypertension: Population based case-control study. BMJ. 2012;344:d8190.

8. Edwards NL. Quality of care in patients with gout: Why is management suboptimal and what can be done about it? Curr Rheumatol Rep. 2011;13:154-159.

9. Sarawate CA, Brewer KK, Yang W, et al. Gout medication treatment patterns and adherence to standards of care from a managed care perspective. Mayo Clin Proc. 2006;81:925-934.

10. McCarthy GM, Barthelemy CR, Veum JA, Wortmann RL. Influence of antihyperuricemic therapy on clinical and radiographic progression of gout. Arthritis Rheum. 1991;34:1489-1494.

11. Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharma-cologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64:1431-1446.

12. Stamp L, Searle M, O’Donnell J, Chapman P. Gout in solid organ transplantation: A challenging clini-cal problem. Drugs. 2005;65:2593-2611.

13. Pegloticase (Krystexxa) [package insert]. Bridgewater, NJ: Savient Pharmaceuticals, Inc; 2012.

14. Reinders MK, Jansen TL. New advances in the treatment of gout: Review of pegloticase. Ther Clin Risk Manag. 2010;6:543-550.


Prophylaxis During Urate-Lowering TherapyAs noted, the goal of prophylaxis is to lower serum uric acid levels to the point at which gouty attacks will not occur over the long term. For most patients, this means lowering levels to below the threshold of 6 mg/dL. Initially, many patients experience acute attacks as the body’s stores of urate are pulled into the circulation—a process that some clinicians refer to as “crystal stripping” or “mobilization attacks.”

Because patients are so much more likely to experience acute gout attacks during hyperuri-cemic therapy, the 2012 ACR guidelines recommend initiating and maintaining prophy-lactic anti-inflammatory therapy while lowering serum uric acid levels. The medications used for this purpose are the same as those used for acute attacks, although at lower doses than those used to treat acute gout.2

The guidelines recommend colchicine or an NSAID as the first line of therapy for chronic use and using low-dose prednisone only if colchicine, an NSAID, or a combina-tion of the two fails to adequately keep inflammation controlled or in cases in which patients cannot tolerate these two drugs. A consensus was not reached about whether anti–IL-1 therapy should be used prophylacti-cally, although several prospective, blinded trials suggest that such a strategy is effective.2

Failure to Reach Target Serum Uric Acid LevelsWhen patients are taking urate-lowering medi-cations (ie, allopurinol or febuxostat) and have not reached target serum uric acid levels, given an adequate trial, medication dosages should be titrated upward to the maximal appropriate dosage. If this approach is still not adequate, addition of a uricosuric agent is recommended in patients with adequate renal function;

probenecid or, alternatively, the antihyperten-sive losartan—or the lipid-lowering agent fenofibrate—may be added. If these do not result in achievement of the target urate level and the disease remains active, consideration of pegloticase therapy is appropriate.

SummaryTreatment approaches to acute gouty arthri-tis (commonly referred to as acute gout) target two areas: (1) managing the inflam-mation that results from spontaneously precipitated or mobilized predeposited tissue stores of MSU crystals and (2) reducing the conditions permitting future attacks by managing hyperuricemia.

New understanding regarding the patho-genesis of acute gout and mechanisms of action of traditional therapies for acute gout and hyperuricemia has allowed the develop-ment by the ACR of the first US evidence-based treatment recommendations. The standard anti-inflammatory medications for the man-agement of acute gout—colchicine and NSAIDs—are still the mainstay of therapy. ACTH, once FDA approved for gout, is now an off-label therapy that may be considered in selected cases. IL-1–directed therapies, several of which are approved for other indications, currently are being investigated for the treat-ment of acute gout; according to the ACR guidelines, these agents also may be consid-ered for off-label use in selected patients.

The mainstay of treatment for urate lower-ing in patients with hyperuricemia is allopurinol, starting at 100 mg/day and slowly titrating upward to a level sufficient to lower serum urate to less than 6.0 mg/dL. Febuxostat and pegloticase are important, more recently available agents that may be considered in appropriately selected patients.

The guidelines also provide specific recom-mendations for anti-inflammatory therapy to be used prophylactically during urate-

lowering treatment, as the reduction of serum urate levels commonly causes attacks of acute gouty arthritis. n

References1. Khanna D, Fitzgerald JD, Khanna PP, et al. 2012

American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharma-cologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64:1431-1446.

2. Khanna D, Khanna PP , Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiin-flammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64:1447-1461.

3. Giclas PC, Ginsberg MH, Cooper NR. Immunoglobulin G independent activation of the classical complement pathway by monosodium urate crystals. J Clin Invest. 1979;63:759-764.

4. Busso N, So A. Mechanisms of inflammation in gout. Arthritis Res Ther. 2010;12:206.

5. Malawista SE, de Boisfleury AC, Naccache PH. Inflammatory gout: Observations over a half-cen-tury. FASEB J. 2011;25:4073-4078.

6. Martinon F, Petrilli V, Mayor A, Tardivel A, Tschopp J. Gout-associated uric acid crystals acti-vate the NALP3 inflammasome. Nature. 2006; 440:237-241.

7. Getting SJ, Lam CW, Chen AS, Grieco P, Perretti M. Melanocortin 3 receptors control crystal-induced inflammation. FASEB J. 2006;20:2234-2241.

8. So A, De Smedt T, Revaz S, Tschopp J. A pilot study of IL-1 inhibition by anakinra in acute gout. Arthritis Res Ther. 2007;9:R28.

9. Terkeltaub RA, Schumacher HR, Carter JD, et al. Rilonacept in the treatment of acute gouty arthritis: A randomized, controlled clinical trial using indo-methacin as the active comparator. Arthritis Res Ther. 2013;15:R25.

10. So A, De Meulemeester M, Pikhlak A, et al. Canakinumab for the treatment of acute flares in difficult-to-treat gouty arthritis: Results of a mul-ticenter, phase II, dose-ranging study. Arthritis Rheum. 2010;62:3064-3076.

11. Dalbeth N, House ME, Horne A, Petrie KJ, McQueen FM, Taylor WJ. Prescription and dosing of urate-lowering therapy, rather than patient behaviours, are the key modifiable factors associ-ated with targeting serum urate in gout. BMC Musculoskelet Disord. 2012;13:174.

Acute Gouty Arthritis: Issues and Recommendations for Prophylaxis and Treatment continued from page 5

In addition to reducing consumption of these sugars, dietary supplementation with more dairy products and nutriceuticals such as cherry juice extract may exert some benefit. These measures have not been shown to reduce serum urate to levels low enough to permit the dissolution of urate deposits in tissue, but following a heart-healthy diet, avoiding fructose and extremely high purine-content foods (such as organ meats and beer), consum-ing low-fat dairy foods, and maintaining a reasonable weight may all be helpful in con-trolling the serum urate level. Binge drinking or drinking several “cocktails” followed by periods of low food ingestion has been shown to elicit gout attacks. Ingestion of ascorbic acid supplementation likely has a minimal effect at lowering the urate level.

Medication EffectsPatients with gout have an extremely high preva-lence of coexistent metabolic syndrome. Thus, they are frequently on medications for treatment or prevention of cardiovascular diseases includ-ing coronary syndromes (aspirin, statins) and hypertension (thiazides), which can raise the serum urate level. However, neither cardiopro-tective (low-dose) aspirin or thiazide diuretics will significantly elevate the serum urate level; the increases that occur are usually much less than 1 mg/dL, certainly not above what can easily be managed by a slight increase in the dosage of a xanthine oxidase inhibitor. Given

the proven value of aspirin prophylaxis and good control of hypertension, I do not stop these medications in patients with gout.

SummaryIn patients with known gouty arthritis, the currently recommended target rate of serum urate is below 6 mg/dL. The xanthine oxidase inhibitor allopurinol, used at an appropriately high enough dosage, is a cost-effective and clini-cally efficacious agent and remains a mainstay of urate-lowering therapy. The newer xanthine oxidase inhibitor febuxostat is an alternative and is particularly useful in patients with toler-ance, hypersensitivity, or allergic reactions to allopurinol. The newest addition to the roster of treatment options is pegloticase, which is appropriate for patients who are refractory to antihyperuricemic treatment with conven-tional agents or in whom the conventional agents are contraindicated. Pegloticase is espe-cially useful for patients with macrotophaceous gout, in whom rapid lowering of serum urate to very low levels is desirable. The goal of lowering serum urate is to decrease the burden of uric acid deposition over the long term. n

References1. Khanna D, Fitzgerald JD, Khanna PP, et al. 2012

American College of Rheumatology guidelines for management of gout. Part 1: Systematic nonpharma-cologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012; 64:1431-1446.

2. Burns CM, Wortmann RL. Latest evidence on gout management: What the clinician needs to know. Ther Adv Chronic Dis. 2012;3:271-286.

3. Becker MA, Schumacher HR Jr, Wortmann RL, et al. Febuxostat compared with allopurinol in patients with hyperuricemia and gout. N Engl J Med. 2005; 353:2450-2461.

4. Becker MA, Schumacher HR, Espinoza LR, et al. The urate-lowering efficacy and safety of febuxostat in the treatment of the hyperuricemia of gout: The CONFIRMS trial. Arthritis Res Ther. 2010;12:R63.

5. Pegloticase (Krystexxa) [package insert]. Bridgewater, NJ: Savient Pharmaceuticals, Inc; 2012.

6. Reinders MK, Jansen TL. New advances in the treatment of gout: Review of pegloticase. Ther Clin Risk Manag. 2010;6:543-550.

7. Perez-Ruiz F, Alonso-Ruiz A, Calabozo M, Herrero-Beites A, Garcia-Erauskin G, Ruiz-Lucea E. Efficacy of allopurinol and benzbromarone for the control of hyperuricaemia: A pathogenic approach to the treatment of primary chronic gout. Ann Rheum Dis. 1998;57:545-549.

8. Stamp LK, Taylor WJ, Jones PB, et al. Starting dose is a risk factor for allopurinol hypersensitivity syn-drome: A proposed safe starting dose of allopurinol. Arthritis Rheum. 2012;64:2529-2536.

9. Taylor TH, Mecchella JN, Larson RJ, Kerin KD, Mackenzie TA. Initiation of allopurinol at first medical contact for acute attacks of gout: A random-ized clinical trial. Am J Med. 2012;125:1126-1134.

10. Choi HK, Willett W, Curhan G. Fructose-rich beverages and risk of gout in women. JAMA. 2010;304:2270-2278.

11. Johnson RJ, Sautin YY, Oliver WJ. Lessons from comparative physiology: Could uric acid represent a physiologic alarm signal gone awry in western society? J Comp Physiol B. 2009;179:67-76.

12. Zgaga L, Theodoratou E, Kyle J, et al. The association of dietary intake of purine-rich vegetables, sugar-sweetened beverages and dairy with plasma urate, in a cross-sectional study. PLoS One. 2012;7:e38123.


Current Options for Managing Hyperuricemia continued from page 7

disease, in whom gout is sometimes misdiag-nosed and mistreated because gout or other crystal-associated arthritis—such as calcium pyrophosphate crystal deposition disease (pseudogout) or apatite arthritis—has not been considered in the differential diagnosis.

Emerging approaches in diagnostic imaging—ultrasonography and dual-energy computed tomography (DECT) scan— may provide tools that are less invasive and yield more rapid results. Rheumatologists in the United States are beginning to use high-resolution ultrasonography to diagnose gout. Ultrasonography may be almost as specific as microscopic detection of crystals in a synovial aspirate; however, the sensitivity and accuracy of results—primarily, demon-stration of the “double contour” sign—is highly dependent on operator skill.12 Improvements in equipment and skills may make this modality more widely useful.

Conventional computed tomographic scan-ning does not have a significant current role in the diagnosis of gout. It does demonstrate the extent of bone damage, a finding that can be helpful in persuading patients of the need to comply with their prescribed treatment regimen, but plain films usually suffice for this

purpose.12 DECT is an emerging technique that can produce striking images.13 However, its use to date has been primarily in patients with chronic tophaceous disease, in whom diagnosis is rarely a problem.12

SummaryThe prevalence of gout in the United States has increased markedly in recent years. This change has been linked to lifestyle changes, especially to excessive dietary intake of fruc-tose. The demonstration of MSU crystals in aspirates of synovial f luid or other tissue remains the pathognomonic and most specific finding in gouty arthritis. Ultrasonographic and computed tomographic technologies show promise in diagnosing gout but are not yet widely used in the United States. n

References1. Lawrence RC, Felson DT, Helmick CG, et al, for

the National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part II. Arthritis Rheum. 2008;58:26-35.

2. Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: The National Health and Nutrition Examination Survey 2007-2008. Arthritis Rheum. 2011;63:3136-3141.

3. Hak AE, Choi HK. Menopause, postmenopausal hormone use and serum uric acid levels in US women—the Third National Health and Nutrition Examination Survey. Arthritis Res Ther. 2008;10:R116.

4. Choi HK, Willett W, Curhan G. Fructose-rich beverages and risk of gout in women. JAMA. 2010;304:2270-2278.

5. Johnson RJ, Sautin YY, Oliver WJ. Lessons from comparative physiology: Could uric acid represent a physiologic alarm signal gone awry in western society? J Comp Physiol B. 2009;179:67-76.

6. Rho YH, Zhu Y, Choi HK. The epidemiology of uric acid and fructose. Semin Nephrol. 2011;31:410-419.

7. Zgaga L, Theodoratou E, Kyle J, et al. The association of dietary intake of purine-rich vegetables, sugar-sweetened beverages and dairy with plasma urate, in a cross-sectional study. PLoS One. 2012;7:e38123.

8. Forbess LJ, Fields TR. The broad spectrum of urate crystal deposition: Unusual presentations of gouty tophi. Semin Arthritis Rheum. 2012;42:146-154.

9. Pillinger MH, Goldfarb DS, Keenan RT. Gout and its comorbidities. Bull NYU Hosp Jt Dis. 2010; 68:199-203.

10. Schlesinger N. Diagnosis of gout. Minerva Med. 2007;98:759-767.

11. Malik A, Schumacher HR, Dinnella JE, Clayburne GM. Clinical diagnostic criteria for gout: Comparison with the gold standard of synovial fluid crystal analysis. J Clin Rheumatol. 2009;15:22-24.

12. Perez-Ruiz F, Dalbeth N, Urresola A, de Miguel E, Schlesinger N. Imaging of gout: Findings and utility. Arthritis Res Ther. 2009;11:232.

13. Choi HK, Al-Arfaj AM, Eftekhari A, et al. Dual energy computed tomography in tophaceous gout. Ann Rheum Dis. 2009;68:1609-1612.

Gout: Demographics, Diagnosis, and Description continued from page 3

© 2013 Global Academy for Medical Education, LLC. All Rights Reserved.

To get instant CME credits online, go to http://uofl.me/gout2013. Upon successful completion of the online test and evaluation form, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail. Please add [email protected] to your e-mail “safe” list. If you have any questions or difficulties, please contact the universityoflouisvilleschoolofMedicineContinuingMedicaleducation(CMe&PD) office at [email protected].

EVALUATION FORMWe would appreciate your answering the following questions in order to help us plan for other activities of this type. All information is confidential. Please print.Name: __________________________________________________________

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Courseevaluation:GaPsThis activity was created to address the professional practice gaps listed below. Please respond regarding how much you agree or disagree that the following gaps were met:• Gouty arthritis is often a chronic condition; with early diagnosis and treatment,

most patients experience improvement.• In addition to prompt diagnosis and optimal therapy, clinicians must be prepared to

consider and manage comorbid conditions.• Management of this chronic disease also entails commitment from the patient and requirespatient-physiciancommunicationtooptimizetreatmentselectionandoutcomes.

• New concepts concerning the genetics of hyperuricemia, the dynamics of the metabolic syndrome, and the renal handling of uric acid have emerged, and their implications for future therapy are being explored.

• Clinical guidelines for the treatment of gout are often not widely observed, which leads to the condition often being suboptimally treated, with urate-lowering drugs not being adequately dosed.

• Because of the observation that sudden lowering of serum uric acid levels was likely to cause an acute attack of gout, the prevailing belief was that treatment to lower uric acid levels during an acute flare was likely to increase the severity. Theresultsofarecentrandomizedtrialsuggestthatbeginningtreatmentforhyperuricemia during an acute gout attack might be beneficial, if prophylaxis is started simultaneously.

Did participating in this educational activity improve your KNOWLEDGE in the professional practice gaps that are listed on the left?

Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree1 2 3 4 5

Please elaborate on your answer. ______________________________________ _______________________________________________________________ _______________________________________________________________

Did participating in this educational activity improve your COMPETENCE in the professional practice gaps that are listed on the left?


Please elaborate on your answer. ______________________________________ _______________________________________________________________ _______________________________________________________________

Did participating in this educational activity improve your PERFORMANCE in the professional practice gaps that are listed on the left?


Please elaborate on your answer. ______________________________________ _______________________________________________________________ _______________________________________________________________Please identify a change that you will implement into practice as a result of participating in this educational activity (eg, new protocols, different medications). _______________________________________________________________ _______________________________________________________________How certain are you that you will implement this change?


What topics do you want to hear more about, and what issue(s) in your practice will they address? ____________________________________________________ _______________________________________________________________ _______________________________________________________________Were the patient recommendations based on acceptable practices in medicine? m Yes m NoIf no, please explain which recommendation(s) was (were) not based on acceptable practices in medicine. ______________________________________________ _______________________________________________________________ _______________________________________________________________Do you think the articles were without commercial bias? m Yes m NoIf no, please list the article(s) that was (were) biased. _______________________ _______________________________________________________________

Meeting Clinical Challenges in Gout: Diagnostic and Treatment Guidelines for Improved Patient Outcomes CME Post-Test Answer Sheet and Evaluation Form

Release Date of Activity: August2013•Expiration Date of Activity for AMA PRA Credit:August31,2015•Estimated Time to Complete This Activity: 2.0 hours

The University of Louisville thanks you for your participation in this CME activity. All information provided improves the scope and purpose of our programs and your patients’ care.

1. Increased interest has been paid recently to lesscommonsitesoftophi,includingthespine,theouterridgesoftheear,thekidneys,andthe:A. Cardiac valvesb. Endocrine glandsC. Muscle tissueD. Skull

2. thegoldstandardtestforgout—ie,detectionof crystals in aspirated synovial fluid or tissue from a symptomatic joint in the absence of infection—is performed in an estimated _________ of cases.A. 5%b. 10%C. 15%D. 20%

3. Which one of the following drugs works by inhibiting the ability of cells to manage microtubular function?A. Allopurinolb. ColchicineC. IndomethacinD. Pegloticase

4. The 2012 American College of Rheumatology guidelines for the management of gout recommend reducing urate to a level less than ____mg/dltopreventtheformationofnewmonosodium urate crystals and permit the resorption of established crystal deposits.A. 4.0b. 5.0C. 6.0D. 7.0

5.Whichoneofthefollowingurate-loweringmedications has been shown to rapidly lower serumuratelevels,insomecases,tolessthan1mg/dl?A. Allopurinol, at doses exceeding 800 mg/dayb. FebuxostatC. PegloticaseD. Probenecid

6. Most of the urate in serum is derived from _____.A. Alcoholb. Cellular metabolismC. Purine-rich foodsD. Sugars

7. atleastonecomorbidcondition (eg,hypertension,type2diabetes,chronickidney disease [CKD]) is seen in at least ____ of the population of patients with gout.A. 5%b. 10%C. 15%D. 20%

8. Which one of the following statements is true concerningurate-loweringtherapyinpatientswith CKD?A. Allopurinol should be started at low dosages

but can be safely titrated upward to treat to the target serum urate level, even in patients with renal dysfunction.

b. Febuxostat is eliminated in its active form by the kidney.

C. Nonsteroidal anti-inflammatory drugs are a good choice for prophylaxis of acute flare symptoms for most patients with significant CKD.

D. Probenecid can be especially effective in patients with glomerular filtration rates less than 50 mL/min.

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