Background In spite of good treatment options results in surveys of gout have been disappointing. In general practice only 50% of gout pt.s are put on urate lowering treatment (ULT) and of these less than 50% reach the curative treatment target (TT)(p-Urate <0.36 mmol/l) rendering many pt.s prone to experience continuous disease activity or repeating flares. In order to improve gout treatment EULAR and ACR have elaborated guidelines based on the treat to target concept with gradually intensified ULT combined with flare prophylaxis.
Objectives To evaluate the eligibility and effectiveness of the EULAR/ACR guidelines in clinical practice.
Methods 100 consecutive pt.s diagnosed with crystal proven gout were offered personal disease information and a standardized treatment regime. ULT was started with allopurinol (ALL) 100 mgs daily and the dose was gradually increased at follow up visits typically every 6 weeks until TT was reached. Pt.s with known or new incident ALL intolerance were treated with/changed to febuxostat (FEB) or benzbromaron (BEN). All pt.s were unless contraindicated offered flare prophylaxis with colchicine (COL) 0.5 mgs bid as long as they had clinical symptoms or were dose escalated in ULT. The pt.s were offered to be followed until their reached “Clinical Remission” defined as TT reached for 3 months and no flares and no flare prophylaxis for the last month.
Results 88 males (62,1±13,6 (SD) yr) and 12 females (74,1±6,9 yr) were included. Mean disease duration was 8,6±6,9 years. 18 had mon-, 37 oligo-, 25 polyarticular, and 20 had tophaceous gout. Recently affected joints included MTPs: 63%, midfoot/ankles: 57%, knees: 57%, hands/wrists/elbows: 47%. Most patients had comorbidity in the form of CVD: 36%, Hypertension: 80%, DM2: 28%, and nephropathy: 29%. 72% had Metabolic Syndrome. At entry 15 pt.s were on ALL treatment. P-urate was initially 0.53±0.11 mmol/l in untreated pt.s and 0.46±0.10 mmol/l in ALL treated pt.s.
93 pt.s started/continued ULT (ALL: 86, FEB: 12, BEN: 7). 85% reached TT after mean 4.7±3.9 months. 40% reached p-Urate <0.40 mmol/l. Median ALL dose was 300 mgs daily, 17% and 11% needed 450 and 600 mgs respectively. 90% received COL prophylaxis with mean treatment duration of 7.6±5,8 months. “Clinical Remission” was reached in 82 of 100 gout pt.s after mean treatment duration of 10.4±5.6 months. The mean number of visits were 5.5±2.4 and follow up timewas11.1±5.6months. The 18 patients who did not reach “Clinical Remission” either did not want any treatment (n=3), did not want ULT due to previous experience with flares (n=4), had bad compliance (n=6), could not reach TT due to co-morbidity with nephropathy (n=2), or were due to AEs satisfied with insufficient ULT and continuous COL treatment (n=3).
Conclusions Reaching a good treatment result in gout still is challenging due to extensive morbidity and co-morbidity. This study shows that a good clinical response can be achieved in the majority of patients when given personalized disease information and long term follow up with long term flare prophylaxis in compliance with the EULAR/ACR guidelines. It is suggested that rheumatologists assume the role of following gout patients until they have reached TT and clinical remission and subsequently can be followed in general practice.
Disclosure of Interest None declared