Although the guidelines address treatment options, they were not designed and are not intended to affect decisions about insurance coverage, Dr. Fitzgerald adds. “Our hope is that the recommendations will be used at the doctor–patient interaction level.”
Pharmacologic and Nonpharmacologic Approaches
Part I of the guidelines focuses on nonpharmacologic and pharmacologic therapy of hyperuricemia associated with gout. The recommendations are built around three distinct treatment groups, each subdivided into three case scenarios that represent clinically based decision making. These nine case scenarios are delineated by symptom severity, the number of joints involved, the size of the joints, the uric acid burden, and the severity of joint destruction.
Cases 1 through 3 include the treatment group with intermittent attacks of acute gout but no tophi on physical exam, further subdivided into the frequency of acute gouty episodes of either moderate to severe pain. Cases 4 through 6 include scenarios of gout associated with clinically apparent high body urate burden. These cases have one or more tophi and intermittently symptomatic gouty arthritis. Cases 7 through 9 represent scenarios of chronic tophaceous gouty arthropathy, which differ by the extent and characteristics of tophi and chronic arthropathy, with variable inflammatory and deforming features that can be detected by physical examination.
Recommendations are given for specific dosing regimens and escalation of pharmacologic urate-lowering therapies for each of the case scenarios, beginning with a first-line xanthine oxidase inhibitor (XOI). The treat-to-target serum urate level recommended is fewer than 6 mg/dL at a minimum, according to Dr. Puja Khanna, with lowering serum urate to fewer than 5 mg/dL needed for improvement in signs and symptoms in some patients, especially to promote more rapid lowering of total body uric acid burden.
Physicians should consider causes of hyperuricemia for all patients, according to the guidelines, including evaluating the agents and conditions that could lead to either underexcretion or overproduction. “We see gout as a biomarker, essentially, of people having serious metabolic and cardiovascular diseases,” Dr. Terkeltaub says. “We point out that the caregiver should have a basket of things to think about when the gout patient limps or walks into their office.”
This “basket” of concerns includes not only comorbidities but also diet and lifestyle issues, with recommendations given for avoiding organ meats, beverages and foods with high fructose corn syrup, and overuse of alcohol (especially beer); limiting serving sizes of meats, seafood, table sugar, and salt; and encouraging consumption of vegetables and lowfat or nonfat dairy products.