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Gout: a curable Disease that often is undertreated: long-term treatment is proven and available, but most patients and their physicians continue to take a short-term approach.

Gout, one of the most understood and common forms of inflammatory arthritis, is not only treatable, but curable as well. Yet, researchers in Europe and the United States tell us that the incidence of gout continues to rise, that less than half of patients seek treatment for the specific condition, and even fewer take advantage of urate-lowering therapy (ULT), which is known to effectively "cure" the disease.

A 2012 study published in Annals of the Rheumatic Diseases (ARD) found that in the U.S., 3.9 percent of adults (more than 8 million) are affected, and that the rate increases to seven percent of men over 65, slightly less for women. However, there is an incorrect perception that gout is largely self-inflicted and responds only to short-term, symptom-based treatment.

The authors of the study concluded that only a minority of patients with gout receives adequate advice and treatment, and that ULT is underprescribed and often underdosed.

A study published online January 15, 2014 in ARD found that less than half of gout patients had physician consultations specifically for gout, and that just 37 percent received ULT therapy. In addition, only 18 percent of patients began treatment within six months of being diagnosed with gout.

WHAT IS IT? WHY IS IT SO PAINFUL? Gout is a disease that usually affects a single joint--often the big toe--but can involve the an-kles, knees, wrists, and elbows. The affected joint is so tender that the slightest contact can cause severe pain. The skin around the joint will become swollen, red, and shiny, and an untreated episode can last for five to15 days. Some people never have another incident, others may not have an attack for years, and still others can expect another episode of gout within 12 months.

Gout develops when an excess of uric acid exists in the body, causing needle-like crystals to be deposited in the joints. It can happen because the body produces too much uric acid or because the kidneys cannot remove the acid fast enough.

Certain foods, drinks, and medications may raise the uric acid level. These include shellfish, red meat, alcohol, and foods/drinks high in fructose, as well as medications such as low-dose aspirin, diuretics, and certain immunosuppressants, 111-1 such as cyclosporine.

THE TREATMENT. Acute attacks respond to the drug colchicine, which is effective if administered early, but which in high doses may cause nausea, diarrhea, and other side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Indocin and Naprosyn, decrease inflammation and pain. Severe attacks may require a stronger drug called Kineret.

Chronic gout, however, must be prevented by medications that reduce the formation of uric acid (Aloprim, Zyloprim, Uloric). They should not be taken during an acute episode. Once the uric acid level drops below 6 mg/ dL, crystals tend to dissolve, but a person has to stay on the medication for the long term to avoid a recurrence.


Many patients do, but quit after a period of not having attacks. Others wait and hope not to have another episode. Also, treatment is not effective unless it is tailored to individuals.

The two Annals of the Rheumatic Diseases studies suggest that treating gout is not a priority in medical education programs. And until recently, there had been an absence of new medications.

The second problem has been addressed, but the information has not reached enough physicians and their patients to reverse the trend of higher incidence. These new developments may open a "window of opportunity" for gout management and an improved standard of care.

IMICHAEL S. HERSHFIELD, MD, Professor of Medicine and Biochemistry, Duke

Chronic Gout Requires Aggressive Treatment

"Both Annals of Rheumatic Diseases papers address the reasons for the gap between the availability of effective therapy for gout and the failure of too many physicians and patients to prescribe and use it correctly. Perhaps MDs need to recognize two types of gout patient--those with a recent onset of gout attacks, and those whose gout has already progressed to a chronic, debilitating stage. In the former, the goal of preventing progression by keeping serum uric acid at 6 mg/dL or below can be met with better education and better monitoring of uric acid levels, to make sure urate-lowering therapy is being properly dosed and used. In patients with chronic gout, regardless of how they got to this point, eliminating crystal deposits that accumulated over decades is much more difficult than preventing their formation in the first place. I think it requires a more aggressive strategy: Maintaining serum uric acid at below 2 mg/cIL for several months. This can be achieved, and the benefit can be dramatic for the chronic gout patient, and practice-changing for his/her physicians."

Ed. Note: Dr. Hershfield is a co-inventor of pegloticose, which has been approved by the U.S. Food and Drug Administration as a treatment for refractory gout; he and Duke University receive royalties from the sale of pegloticase.


Gout-friendly foods               Foods to avoid
Complex carbohydrates             Meat, poultry, and fish
Fruits, vegetables, whole grains  Saturated fat
Low- or fat-free dairy products   High-fructose corn syrup
Fluids, especially water          Alcohol
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Author:Hershfield, Michael S.
Publication:Duke Medicine Health News
Date:Aug 1, 2014
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