Part 1 – Talking about gout: time for a re-think www.bpac.org.nz/2018/gout-part1.aspx
Part 2 – Controlling gout with long-term uratelowering treatment www.bpac.org.nz/2018/gout-part2.aspx
Gout and CV outcomes – Gout is much more than an
intensely painful condition. People with gout are more
likely than those without gout to die at a younger age due
to cardiovascular and renal complications. In New Zealand,
40% of people with gout have diabetes and/or cardiovascular
disease. Despite this, many patients consider gout to be a
condition that merely requires analgesics to control and are
not aware of the potential long-term consequences.
Disparities exist – Māori and Pacific peoples are
disproportionately affected by gout and often receive suboptimal
care. Gout is more frequent and more severe in Māori
and Pacific peoples and they are not receiving the medicines
they need to manage their health effectively
Delaying initiation – Urate-lowering treatment is often
delayed well beyond the point when it is indicated.
Furthermore, once urate-lowering medicines are started,
monitoring is often sub-optimal and many patients will
still have serum urate concentrations above recommended
levels. The barriers to the early and optimal use of uratelowering
medicines are multi-factorial. The limited time
that is available in consultations in primary care and the
intermittent nature of gout flares also makes the long-term
management of gout difficult.
Urate-lowering treatment and monitoring – Allopurinol is
started at a low dose and slowly titrated upwards, to minimise
adverse effects, until the patient reaches the target serum
urate level. Allopurinol can be safely used in patients who
have reduced renal function, with a lower starting dose and
slower titration. Dose reductions are not routinely required
in patients with declining renal function who are already
established on allopurinol. Once allopurinol has been initiated,
regular follow-up with serum urate testing is required while
the dose of allopurinol is titrated upwards, until the serum
urate target is reached.
Monitoring patients with gout – Patients with gout need to be monitored to:
- Ensure serum urate levels are reached and remain below saturation point
- Encourage ongoing treatment adherence
- Manage cardiovascular risk factors
- Treat any co-morbidities that may emerge
Regular exercise and weight loss, where appropriate, should
underlie all strategies to prevent the development of diabetes
and cardiovascular disease. Patients with gout that is wellcontrolled
with urate-lowering medicines should have at least
annual assessments of serum urate, renal function, HbA1c and
blood pressure.
- In your experience do you think that patients understand
that gout can have other implications for their future
health? Do you find that patients are receptive to this
information or just want their pain settled?
- Were you aware of the extent of the disparities among
Māori and Pacific peoples in regards to gout? What
strategies, if any, do you have in place in your practice to
help address these disparities?
- Around 50% or less of patients with gout are prescribed
urate-lowering medicines such as allopurinol, although
statistics vary. Do you find this figure surprising? If so,
what do you think are the barriers in your community
and your practice that might reduce optimal
management of gout?
- There is increasing evidence that supports initiation of
urate-lowering treatment at the time of a flare rather
than delaying until the flare has resolved. Have you
prescribed allopurinol during a flare? Do you think this
will assist with improved management of gout in the
longer term?
- Allopurinol is the first-line urate-lowering
medicine, however, there are others
available if allopurinol is not tolerated,
is contraindicated or targets are not
achieved. What is your experience of
prescribing urate-lowering medicines
other than allopurinol? If you have not
prescribed these medicines, has reading
this article made you feel more confident to
now do so?
