The ACR’s Gout Guideline Co-Author Shares Insight on Treating Pain, Ongoing Patient Care

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WASHINGTON, D.C.—Despite the value of guidelines, they often “are not read,” said N. Lawrence Edwards, MD, professor of medicine specializing in rheumatology at the University of Florida, at the 2016 ACR/ARHP Annual Meeting talk titled, New & Emerging Therapies for Gout, as part of the ACR Review Course. Or if they are read, they aren’t “remembered very well,” he noted.

During the session, Dr. Edwards gave attendees a kind of guided tour of the latest guideline for gout management, driving home certain points with emphasis and explanation. As one of the authors of the gout guideline released by the ACR in 2012, Dr. Edwards offered tips and insights related to treating severe gout pain and ongoing patient care.^1,2

Treatment Strategies

The guideline includes separate and distinct recommendations for the treatment of acute pain and inflammation and for lowering urate. “The urate-lowering therapy has nothing to do with controlling acute pain and inflammation, nor do the anti-inflammatory and pain-controlling mechanisms have any beneficial effect on urate lowering,” he said.

Dr. Edwards outlined a series of tips for clinicians treating patients with gout pain:

• For acute symptoms, therapy should optimally be given in the first 24 hours. Patients should have their medication with them at all times—and know how to use it—for those flares that are “going to happen at 3 in the morning.”
• When treating for an acute flare and pain with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, glucocorticoids or an IL-1 inhibitor, don’t interrupt urate-lowering therapy.
• Anti-inflammatory prophylaxis, with colchicine, NSAIDs or an IL-1 inhibitor, should be used in all gout patients before starting urate-lowering therapy, usually about a week or two before.
• Treating pain yields slow results. Pain will be reduced only by one-half within 36–48 hours, and patients should be prepared for that. “That’s not a very … encouraging bit of information, because most of these people are in excruciating pain,” Dr. Edwards said.
• If a patient’s pain affects more than one area or if he or she has failed monotherapy, combinations may be used.
• Urate-lowering therapies include allopurinol, febuxostat, probenecid, lesinurad and pegloticase.

Patient Education Benefits

Patient education is “what we do worst in gout,” Dr. Edwards said. But it is hugely important, he added. “The reason patients don’t take their medications is [because] they don’t believe it [will help]—because you haven’t told them why they’re taking this.

“If you’re not going to spend the 20–30–40 minutes to tell the patient about the drug and the disease, make sure they find a source of good unbiased information,” he added.