An acute attack of gout causes extreme pain and tenderness that is recognised to be one of the most painful conditions to experience. Furthermore, subcutaneous tophi can cause visible deformity and local pain and inflammation, and clinically occult tophi and chronic subclinical crystal-induced inflammation may irreversibly damage joints and be a risk factor for cardiovascular disease. Therefore it is not surprising that ongoing gout associates with reduced quality of life. From a patients' perspective gout it is something to get rid of as quickly as possible. Unfortunately, although involvement of patients in shared decision-making is recommended best practice, most patients are not asked the question “would you like us to get rid of your crystals as soon as we can or is it OK to take several years to do this?” When they are asked they inevitably vote for option one.
The concept of speed of crystal clearance is relevant to two situations. Firstly, when urate-lowering therapy (ULT) is initiated and the practitioner must decide how low to reduce the patients serum uric acid (SUA) below the target of 360 μmol/L knowing that the lower the SUA the faster the velocity of crystal clearance and the sooner the patient is “cured” (i.e. no urate crystals). Increasingly the case is being made to maintain the SUA <300 μmol/L, at least for the first year or so, to speed up removal of the crystals and their associated detrimental effects. The second situation is the question of when in the lifetime of the patient with gout should successful urate crystal clearance be encouraged by ULT? Again it is increasingly recommended that full patient education, including the option or ULT, should be discussed with the patient early around the time of first diagnosis. When fully informed, the majority of patients with gout opt for ULT rather than wait a number of years until the crystal load has increased even further. In both these situations it is apparent that the speed of crystal clearance does matter both in terms of medical logic and patient preference.
Disclosure of Interest None declared