There is no clear definition of severe gout indeed, several terms refer to severe gout but had not been clearly defined: Severe gout, refractory gout, chronic tophaceous gout, resistant to treatment gout, treatment failure gout. Gout patients frequently have severe associated conditions (metabolic and cardiovascular diseases) that determine its treatment, we will discuss mainly the characteristics and treatment for patients with severe gout per se and gout related renal disease.
The scarce proposals for severe gout definition had considered as severe gout:gout arthropathy in >4 joints or ≥1 unstable, complicated, severe articular tophus or tophi; or frequent oligoarticular flares, numerous tophi, joint damage and musculoskeletal disability or ≥5 tophi and/or intradermal tophi. Based in them, we will consider for this presentation severe gout as ≥5 tophi, frequent flares and chronic structural joint damage.
Treat to target strategies in rheumatology had considered: Remission, prevention of structural damage and improvement of quality of life. Most rheumatologists agree that these 3 outcomes can be obtained in almost all gout patients if they receive adequate treatment since the onset. In this sense, the most frequent cause of severe gout is longtime inadequate treatment that could prevent irreversible changes.
Goals The treatment for severe gout is essentially the same treatment for regular gout, although some characteristics require discussion and alternatives. The objective of the chronic treatment for gout is sUA <6 mg/dL and <5mg/dL or even <4mg/dL in severe cases. In the presentation we will revise some clinical cases of severe gout and discuss important points for treatment according to published guidelines and real, possible treatment.
Allopurinol sub-optimal doses and renal function Many patients with severe gout are the consequence of allopurinol doses strictly adjusted to renal function in order to prevent Allopurinol hypersensitivity syndrome (AHS), in the last decade, several authors coincide that higher doses can be used safely in patients with Gout and this is determinant for improvement in gout and renal variables. AHS is associated in Asia with HLAB*5801, but not in other populations; start low allopurinol doses and careful increase is recommended. High allopurinol doses are reqiired and probenecid can be aggregated to therapy. Also, febuxostat and pegloticase if available, could be used as adjuvant therapy. In some countries benzobromarone is available with good results.
Allergy to allopurinol Is observed in around 5% as first chooice, we use probenecid, plus fenofibrate or losartan when needed. If we can not control acute flares and tophus regression, desensitization to allopurinol is indicated. We start with very low doses (50 μg/day) and increase carefully, we need around 3 months to reach 100 mg/day dose. ul in 7/10 treated patients. Other treatment options for them are febuxostat or pegloticase when available.
Gout modified by chronic glucocorticoid treatment The inappropriate use of glucocorticoids (either by wrong prescription or by self-prescription) is one of the most important causes of severe gout in many countries.In some countries, glucocorticoids can be obtained without medical prescription, they are very cheap drugs (cheaper than NSAIDs) and patients frequently use them for flares, but without chronic ULT. So, they have frequent and severe flares, require higher doses each time and when they attend to Rheumatologists, frequently have secondary Cushing syndrome with all the metabolic complications. For treatment, we use equivalent doses of prednisone and taper it very slowly until stop (mean time 8 months). At the same time, start with allopurinol and add colchicine, antibiotics when needed; some require hospitalization and surgery.
The paper of surgery needs to be stablished, in our experience surgery only should be practiced when tophi complications are associated with infection, tendon, vascular or nerve compressions.
Other clinical conditions very important for the treatment of severe gout patients will be presented and discussed. (early age at onset, lithiasis, role of colchicine etc)
Severe gout is related with low educational and socio-economic level and limited access to health care, auto-prescribed therapy and the use of alternative treatments. The result is sub-optimal treatment for gout due to multiple causes: physicians frequently do not consider gout important task and prescribe sub-optimal treatment, the patients frequently have evasive coping pattern and in some countries, health authorities frequently do not consider gout as an important health problem.
Disclosure of Interest None declared