Abstract

Unlike other chronic arthropathies we have good understanding of gout pathogenesis and have effective treatment strategies to eliminate the pathogenic agent (urate crystals) to effect a “cure”. This is not true however, for calcium pyrophosphate (CPP) or basic calcium phosphate (BCP) crystal associated diseases.

For acute attacks of gout or CPP crystal synovitis best practice, certainly in a hospital setting, is to aspirate and inject the joint with corticosteroid (this is safe, quickly effective and allows confirmation of diagnosis) and then apply ice-packs. If aspiration/injection is not feasible alternatives are: oral steroid; intramuscular injection of steroid or ACTH; oral colchicine (0.5mg 2-4 times daily); oral NSAID/coxib (with PPI); or IL-1 inhibition using a biologic (e.g. anakinra, canakinumab - though currently not licensed for gout). Many patients, however, have contraindications to NSAID and cannot tolerate even “low-dose” colchicine. The same principles of management apply to acute calcific (BCP) peri-arthritis.

Long-term management of osteoarthritis (OA) plus CPP or BCP crystals is the same as that for OA. Low dose colchicine may be helpful for patients with frequently recurring acute CPP crystal synovitis, with or without OA, but there is no long-term treatment to eliminate CPP crystals. In contrast, long-term management of gout aims to: [1] reduce modifiable risk factors (e.g weight loss if obese, stop diuretic if feasible) and [2] use urate lowering therapy (ULT) to reduce and maintain SUA <360 μmol/L to prevent further crystal formation and to dissolve existing crystals. The main ULTs to consider are allopurinol, febuxostat, sulphinpyrazone and benzbromarone - each has its own advantages and disadvantages. Unfortunately, when audited the management of gout is universally suboptimal, the main problems being: [1] ULT is often not given, and when given it is often at a fixed dose and not titrated against a specific SUA target; and [2] patient adherence to ULT is very poor (the worst of any chronic disease). These problems result in common failure to “cure” gout.

Qualitative research has confirmed many barriers to care of gout, both in patients and doctors, including: poor knowledge of gout and its treatment; undue focus on acute attacks alone; patient feelings of guilt and embarrassment due to beliefs that gout is self-inflicted through over-indulgence in food and alcohol; associations with humour and beliefs that it is not a serious condition and is different from “arthritis”. Successful management requires full patient discussion and explanation concerning gout and its treatment, during which such barriers can be addressed. A recent study showed that when patients were fully informed about their gout, 100% wanted to receive ULT and the therapeutic target was achieved and maintained after one year follow-up in more than 9 out of 10 patients. The key challenge therefore is to raise the profile of gout and to improve training, interest and knowledge of doctors so they can impart correct information to their patients.