Reading Rheum

As a relatively recent trainee, gout was described to me as “bread and butter” rheumatology. The management seemed relatively simple because of few drug choices for treating either the acute flare or chronic tophaceous gout. Considering that flares rarely occur when the SUA level is less than 6 mg/dl, it seemed that all we need to do is try to keep the SUA level down. Simple, eh? In fellowship, I soon discovered that every attending had his or her own individual approach to management, and my challenge was to remember each attending’s preferences.

I like this article because it provides evidence-based medicine to support my observation that allopurinol has variable management in terms of follow-up and flare prophylaxis. The multivariate analysis suggests that generally rheumatologists do a better job than other physicians at prescribing flare prophylaxis with allopurinol, although clearly not good enough. I found the low rate of colchicine/NSAID prophylaxis started before or with allopurinol surprising. However, several prior reviews have postulated that inadequate gout flare prophylaxis may contribute to allopurinol discontinuation. The numbers provided here certainly support this line of reasoning.

Recently, the rheumatology community has been fortunate to see the FDA approval of febuxostat this year, with two more drugs (pegylated uricase and rilonacept) hopefully to follow suit. While these drugs have exciting prospects, the findings in the febuxostat APEX and FACT studies have suggested that the safety profile of allopurinol is good.^1,2 Several editorials and commentaries on these studies have indicated that, for many individuals with chronic gout, more aggressive use and titration of allopurinol may be beneficial. The fact that over half of the patients did not have a follow-up SUA check in this study certainly suggests this may be the case.

The study does have some potential areas where it may underestimate drug and laboratory checks. Certainly, it is conceivable that patients may have had their SUAs checked closer to home, and did not make it into the VA system. However, I doubt this accounts for much of the 61% of missing SUA values. Also, it may be that certain nonsteroidal medications were bought over the counter, and thus may have been missed. The authors did perform a separate chart review for colchicine, and found that only 3% of patients had received a colchicine prescription from a non-VA source, which increases the confidence that colchicine use was not significantly missed.

Some may be tempted to read this and think, “I do a better job in my practice.” But is that really the case? Similar studies from the United Kingdom would suggest that we and primary caregivers don’t actually do better in managing gout that the results reported in the article.³ For those of us blessed with certain electronic medical records systems, it is easy enough to look at similar data for our own practice. From my perspective, after reading this study and the febuxostat trials, I am determined to pay more attention to followup uric acids and adjusting the allopurinol doses. And, when I’m on the consult service with the inevitable gout consults, I’ll take a little more time educating the patient and the residents and writing a detailed plan for management in the consult note. Hopefully, with everyone working together, we can diminish the impact of gout, which appears to be staging a serious comeback as one of the most common and disabling rheumatologic conditions.

Reference

Colchicine: An Ancient Drug with Modern Uses

Difficult Gout

Clinical Insights into Gout Management: Rheumatology Drugs at a Glance Pt. 4

Treating Asymptomatic Hyperuricemia Could Lower Risk of Developing Chronic Conditions

Reference

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