Gout Treatment Guidelines and the Effect of Uric Acid Reduction
JUNE 15, 2015
MD Magazine staff
In the MD Insights program “The ‘Disease of Kings:’ Addressing Misperceptions and Treating Gout Effectively Now and in the Future,” Theodore R. Fields, MD, professor of clinical medicine at Weill-Cornell Medical College, and director of the Rheumatology Faculty Practice Plan at Hospital for Special Surgery, discusses gout diagnosis, misperceptions about the disease, and the consequences of undertreatment of this condition. He also reviews current gout treatment options and discusses potential future treatments.
Studies have shown that many patients with gout do not receive guideline-compliant treatment. One recent study found that only about 20 percent of patients who meet the criteria for treatment with a long-term uric acid-lowering drug actually receive treatment.
Many patients simply never receive a prescription for the drug, and a large number of patients who do get prescribed the drugs don’t stay on them. Fields said he thinks is due in large part to lack of education about the medication among patients. “Patients really don’t appreciate how important it is to stay with the drug,” said Fields. Many patients who receive treatment following an attack of gout will stop taking their medication once symptoms subside.
Fields said he recently asked a patient who was being treated with allopurinol how long he stayed on his medication. The patient replied “Oh about a month, and then I thought that was enough and I stopped it.” Although this behavior is fairly typical, it is unfortunate because “there’s such good evidence that staying on this medicine for life is a huge benefit, yet somehow it just doesn’t get across,” said Fields.
He said the key to improving treatment adherence among patients with gout is better education and monitoring. “We’re doing a study at Hospital for Special Surgery in which a trained gout nurse is giving patients a curriculum, teaching them about gout the first day that they come in, educating them about the three different kinds of drugs for gout,” Fields said.
Treatment options include colchicine, which is used “when somebody gets started on a drug like allopurinol to try to prevent an attack,” said Fields. Allopurinol and febuxostat reduce uric acid levels. NSAIDs and other anti-inflammatory medications are used for acute attacks.
Patients are often confused as to the purposes of each drug. “You have drugs for the initial attack, drugs to lower the uric acid, and drugs to prevent an attack when you’re starting a drug to lower the uric acid. So the nurse really educates them and gives them a sense of why they need these different treatments,” Fields said.
As part of the study, “every month a pharmacist calls each patient and asks them if they have any questions, makes sure they’re taking their medicine, makes sure they’re getting the labs that they need, makes sure they have a physician appointment that’s scheduled and they keep up with things,” he said.
The study has revealed a wide range of reasons for why people don’t take their drugs. Fields said he thinks this is representative of what is happening in the community. “I think we really need ways to follow these patients to try to make sure that they understand why they need their drug and why they need to stay on it because we know that if you see them a year later if they stay on the drug the vast majority of them are now gout-free,” he said.
There have also been a number of retrospective studies designed to provide a better understanding of the other effects in the body of lowering the uric acid, beyond helping gout.
It appears that reducing uric acid levels may be associated with a reduction in the number of cardiovascular events and preservation of kidney function (important because many patients with gout also have decreased kidney function).
Fields also said there is some interesting data that indicate low uric acid levels may be associated with increased risk for Parkinson’s disease and Alzheimer’s disease. The study on uric acid levels in Alzheimer’s disease suggested that patients with gout “actually seemed to be protected against Alzheimer’s even if they were treated,” said Fields.