Lifting the lid on patient communications in gout

12 September 2016

There are a variety treatments for gout, and it can be difficult to explain the differences between these to patients in a way that is easy to understand. Here Professor Martin Bergman (USA) shares his favorite approach to describing the treatment options for gout.

Hello, I'm Dr Martin Bergman, Clinical Associate Professor of Medicine at Drexel College of Medicine and a member of TREG. I would like to take a few moments to talk to you about gout. Many of our patients don't fully understand the treatments for gout and are too often willing to treat frequent flares with symptomatic medications, without ever realizing that there are better and more lasting treatment options available to them.

A way that I found helpful in getting my patients to understand, is to compare gout to a boiling pot. From time to time a boiling pot will boil over and spill out onto the stove; this is basically a flare, once this happens we treat simply by cleaning up the mess; in the case of treating gout this may be done with nonsteroidal prednisone or other steroids, joint injections, colchicine, ice, analgesics, frankly whatever works. But, once the mess is cleaned up we still have the issue of the boiling pot. Another thing we can do is to put a lid on the pot, this is what we call prophylaxis; we want to prevent the pot from boiling over and making a mess of the stove. Most of us will use colchicine or nonsteroidals for this purpose. The prophylactic medications however, need to be taken on a continuous basis at least initially or at least until the pot has come to a point where it is no longer boiling over.

However, as we all know even when the pot is covered it can still boil over and make a mess. So rather than just putting a lid on the pot, the best approach would be to turn down the heat. In the case of gout, the heat is too much uric acid in the body. The way we can reduce the heat is to reduce the uric acid burden. For this we use uric acid lowering agents, most rheumatologists will start with an agent that blocks the production of uric acid; such as allopurinol or febuxostat. However, these aren't the only agents currently available; others will try to increase the amount of uric acid that is eliminated through the kidneys. Historically probenecid was used for this purpose but now there is a new agent, lesinurad, which has been shown to work in patients who are on either allopurinol or febuxostat, but continue to have an elevated uric acid level.

Finally, in some cases when the uric acid level is particularly high it's necessary to reduce this by dissolving the uric acid out of the body and pegloticase can be used in this situation. In each of these situations though the goal is to reduce the total body uric acid level to an acceptable range. For most of us this range is generally felt to be less than 6.0 milligrams per deciliter. However, in patients with tophi or a particularly high uric acid burdens, a lot of us will feel that this should be a lower level and will target closer to 5.0 milligrams per decilitre. But it's important to remind the patients that gout flares tend to occur when we are lowering the uric acid levels so it is important that they remain on their prophylactic medications until the final uric acid level is attained and is stable. At that point the pot is no longer boiling so the lid, that is the prophylactic medications, can be removed. The uric acid lowering medications which are lowering the heat will need to be continued indefinitely. Remember, once the heat is turned back on, that is the uric acid is allowed to rise, the likelihood of having a recurrence of flares is virtually guaranteed.

I found this to be a good way to explain the different levels of treatment of gout to my patients of course any discussion of medication should also include the safety risks of that medication being used. Still I hope this gives you another way to discuss gout and it's treatments with your patients. Thank you.

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