Managing gout: There’s more we can do
Acute and chronic gout arthritis are increasingly prevalent, but often poorly managed. This review, based largely on the American College of Rheumatology’s gout guidelines, details the components of high-quality care.
Anti-inflammatory prophylaxis should continue for whichever is greater: 3 months after the target serum urate level is achieved for patients with no evidence of tophi; or 6 months after the target serum urate level is achieved and previously detected tophi have resolved.13
ULT should continue indefinitely,12 with monitoring of serum urate levels every 2 to 5 weeks until the target is achieved and every 6 months thereafter.
Not responding to therapy? Consider nonadherence, refractory gout
If a patient is not responding as expected, consider whether he or she is taking the medication as prescribed. Gout therapy has one of the lowest adherence rates of any chronic disorder.7,8,12,28-30 Studies have found that less than half of patients started on ULT take their medication as prescribed for the entire first year of therapy.9,28
Evidence suggests that nonadherence is especially likely among younger and healthier individuals, possibly because they have little experience managing chronic conditions or needing ongoing care.28-30 Such patients may also be unsure of when and how to take their medication. To promote adherence, physicians should schedule more frequent follow-up appointments after initiating ULT to assess management of the disease and stress the importance of following the medication regimen as prescribed.9,28
Not all patients who don’t respond to ULT are nonadherent, of course. Some have refractory gout. If uric acid levels do not reach the goal of <6 mg/dL (or <5 mg/dL) at the maximum dose of a first-line xanthine oxidase inhibitor, add a uricosuric agent such as probenecid, fenofibrate, or losartan.12
Pegloticase, a pegylated recombinant form of urate oxidase enzyme that converts uric acid to allantoin31 (a water-soluble metabolite of uric acid), is a possible therapeutic option for patients who do not achieve adequate serum urate levels and continue to have symptoms of gout.12 Candidates for pegloticase therapy, which is administered intravenously, include adult patients with gout refractory to conventional ULT or excessive uric acid accumulation due to chemotherapy and those with contraindications to conventional ULT.
Pegloticase is associated with anaphylactic and infusion reactions, requires extensive monitoring, and costs thousands of dollars per month, however. Thus, it is important to carefully evaluate the extent of disease burden (ie, gout symptoms and effect on quality of life) and determine whether the patient has taken ULT and uricosuric drugs as prescribed before considering this option. Pegloticase requires the same anti-inflammatory prophylaxis as other forms of ULT, but there is no consensus on the duration of use.12
CORRESPONDENCE
Tatum Mead, PharmD, University of Missouri-Kansas City School of Pharmacy, Health Sciences Building, Room 2243, 2464 Charlotte Street, Kansas City, MO 64108-2792; meadt@umkc.edu
