He also shared some tips for ongoing gout management:
- Be sure not to overemphasize the role of diet, because a patient might go home and try dietary changes before taking medication. “Even on a pretty restrictive diet, you’re not going to orchestrate much more than a 1 mg/dL decrease in their serum urate level,” he added, “and in virtually no patient with gout is that going to be adequate.”
- Patients should be counseled about their urate-level target. “They should know what their current uric acid level is; they should know what their target is. You should be telling them that.” The typical serum urate target is less than 6 mg/dL. For those with more advanced disease or those with tophi, it’s less than 5 mg/dL.
- Urate-lowering therapies should be used for six months—according to the guideline—and definitely for three months after achieving your target. He said it’s important for patients to know that, with urate-lowering therapies, flare is more likely for the first three months of therapy, so they may actually feel like they are getting worse.
‘Even on a pretty restrictive diet, you’re not going to orchestrate much more than a 1 mg/dL decrease in their serum urate level, & in virtually no patient with gout is that going to be adequate.’ —Dr. Edwards
New Therapies Addressed
Dr. Edwards also discussed new and emerging therapies in gout management, particularly concerning allopurinol and dosing for patients of various ethnicities. His series of recommendations included the following:
- Allopurinol dosing has to be escalated especially carefully for those with chronic kidney disease—an increase of 100 mg/dL per month for those at Stage 3 or better, and an increase of 50 mg/dL per month for those with Stage 4 disease. “This is a slow, laborious process; one that’s safe, one that’s good, but it takes a lot of time on your part,” Dr. Edwards said.
- For patients of Asian descent—and possibly for African-American patients—testing for HLA allele B 5801 is needed. Asians are at a much higher risk of allopurinol sensitivity, and African-Americans are also at a higher risk, although not nearly as much as Asians.
- Febuxostat, although more expensive, doesn’t have to be adjusted according to renal function and is generally better tolerated.
- Emerging therapies for prophylaxis and treatment of acute gout include IL-1 inhibitors anakinra, canakinumab and rilonacept and, possibly, a reentry into the market of ACTHar gel, which has much quicker response, Dr. Edwards said.
- For urate-lowering therapy, emerging treatments include ulodesine, which inhibits urate production, and lesinurad, which promotes excretion of urate through the urine.
“There’s been a paradigm shift in the treatment of gout,” Dr. Edwards said. “We no longer treat symptoms. We treat to target.”
