QD Clinic: Gout: Is it the Journey or the Destination? Save
Dr. Arthur Kavanaugh discusses a gout patient whose frequent flares improved after lifestyle changes, despite medication not being enough on its own.
Transcription
Hello, welcome to Gout QD Clinics on RheumNow. I'm Ry Kavanaugh from San Diego and my title is "Lifestyle and Gout." That's the title I originally came up with, and then just as I was preparing for this I thought maybe I would call it "Gout: Is It the Journey or the Destination?"
So it's a case — a case of a gout patient that I have had for actually quite a while now. This is Mr. J. He is a very typical patient with gout. Very strong family history, from the Philippines. Had gout since he was in his 30s. Risk factors definitely included diet. He would always very sheepishly tell me when he went on trips to the Philippines and the things he had eaten there, which he knew would set off his gout.
The gout had been kind of a problem over some years. When I first saw him he was in his mid-40s, and he was on a diuretic for heart failure. He had the dietary issues as I said, a little bit of alcohol, diet was an important one, family history, but also weight. He was a good 25 to 30 lbs overweight. So we talked about the reversible issues and the irreversible issues, and we had to put Mr. J on allopurinol, and he had his uric acid pretty close to goal — it was at best kind of in the high sixes — but he was having fairly frequent flares of gout. By that I mean about every one or two months. And he knew the routine, we knew the routine. We used NSAIDs, we used colchicine judiciously, kept him on his allopurinol, maximized the dose of that, used prednisone both orally and injectable as needed.
He did okay on this, except it was still not satisfying to either of us because he still had the frequent episodes of gout. And there was a hiatus of time where I didn't see him, and I figured he moved and went to another physician. But then he came back after about four months and he had lost somewhere between 10 and 15 lbs, and I said, "This is great — how did you do it?" And he said, "Well, just eating sensibly and avoiding carbs and taking smaller portions and trying to avoid foods that I know will upset the gout."
The amazing part was that by this time now, he is not having flares of gout. He still has gout, he still had some tophi — those were getting better — and he's still on his medication. But I remember him very, very clearly and really used him as an example when I talked to other gout patients, and told them: listen, you're 40 lbs overweight, you don't need to get to your high school weight, you don't need to get to your fighting weight — if you lose a portion of your excess weight you are probably going to do much better. Using him as an example, and indeed he did do very well, and I took that lesson and tried to share it with patients. Of course, it was always very difficult.
So then he was doing so well that we saw each other less frequently, and then I hadn't seen him for quite some time — this is probably after about six, seven, eight years. I see him again pretty recently and he comes in now still doing well, still doing the good things diet-wise that we had talked about, still maintained on his urate-lowering therapy. But he brings in his son, and his son has had his first episode of gout in his late 20s, and his son is a good 40 to 50 lbs overweight.
So pretty soon, this being this day and age, we have the discussion of: what about those medications, the GLP-1 receptor agonists, and what about using those for gout? And boy, this really got me thinking, and that's the subject of my Gout QD Clinics.
The father did really great with lifestyle modification, which is very difficult and is achieved by only a small portion of patients, but he did really great by doing that. What about using the GLP-1s? I think gout is maybe one of the most prominent conditions that we see for which these therapies could be really dramatically beneficial. But we've all had patients on the GLP-1s where the weight comes down and it's miraculous, and then they stop and the weight goes back up and they're on that seesaw.
And I got to thinking about this, discussing it with the father and his son — now my patient also. I really wish that he would be able to do what his dad did and do it without the medications, because I don't know what's going to happen. I know the GLP-1s may have other benefits and may be immunomodulating, and certainly have benefits across a number of diseases not all of which are related to the weight loss. But in this case, because I have seen people rebound, I wonder what would be better in the long run.
Now, you think of other chronic diseases — someone with high blood pressure, we don't tell them, "Well gosh, lose weight and don't eat any salt and your blood pressure will be lower," which it probably would, but we say, "Here, treat with these blood pressure-lowering medications." The same thing with other types of approach to diabetes — we don't tell people to just
you know just do it naturally and that's somehow better than the therapies that we have. But I think it is pause when you think of some conditions for which people have had difficulty maintaining the lifestyle issues that have been healthy to them and proven healthy in larger populations. And so is it the is it the uh journey or is it the destination? I think uh maybe the journey might matter and some journeys might be more successful than others. Although as we're talking about weight I think it is the destination and getting there quick getting a success is I think is important for lots of patients.
So with gout uh it's a condition I think we've known about for a very long time. I think we have great approaches to our patients and now I think we have more ways to approach them including lifestyle but also some of the newer medications. So this is Arty Kavanagh for the gout QD clinics for RheumNow.
So it's a case — a case of a gout patient that I have had for actually quite a while now. This is Mr. J. He is a very typical patient with gout. Very strong family history, from the Philippines. Had gout since he was in his 30s. Risk factors definitely included diet. He would always very sheepishly tell me when he went on trips to the Philippines and the things he had eaten there, which he knew would set off his gout.
The gout had been kind of a problem over some years. When I first saw him he was in his mid-40s, and he was on a diuretic for heart failure. He had the dietary issues as I said, a little bit of alcohol, diet was an important one, family history, but also weight. He was a good 25 to 30 lbs overweight. So we talked about the reversible issues and the irreversible issues, and we had to put Mr. J on allopurinol, and he had his uric acid pretty close to goal — it was at best kind of in the high sixes — but he was having fairly frequent flares of gout. By that I mean about every one or two months. And he knew the routine, we knew the routine. We used NSAIDs, we used colchicine judiciously, kept him on his allopurinol, maximized the dose of that, used prednisone both orally and injectable as needed.
He did okay on this, except it was still not satisfying to either of us because he still had the frequent episodes of gout. And there was a hiatus of time where I didn't see him, and I figured he moved and went to another physician. But then he came back after about four months and he had lost somewhere between 10 and 15 lbs, and I said, "This is great — how did you do it?" And he said, "Well, just eating sensibly and avoiding carbs and taking smaller portions and trying to avoid foods that I know will upset the gout."
The amazing part was that by this time now, he is not having flares of gout. He still has gout, he still had some tophi — those were getting better — and he's still on his medication. But I remember him very, very clearly and really used him as an example when I talked to other gout patients, and told them: listen, you're 40 lbs overweight, you don't need to get to your high school weight, you don't need to get to your fighting weight — if you lose a portion of your excess weight you are probably going to do much better. Using him as an example, and indeed he did do very well, and I took that lesson and tried to share it with patients. Of course, it was always very difficult.
So then he was doing so well that we saw each other less frequently, and then I hadn't seen him for quite some time — this is probably after about six, seven, eight years. I see him again pretty recently and he comes in now still doing well, still doing the good things diet-wise that we had talked about, still maintained on his urate-lowering therapy. But he brings in his son, and his son has had his first episode of gout in his late 20s, and his son is a good 40 to 50 lbs overweight.
So pretty soon, this being this day and age, we have the discussion of: what about those medications, the GLP-1 receptor agonists, and what about using those for gout? And boy, this really got me thinking, and that's the subject of my Gout QD Clinics.
The father did really great with lifestyle modification, which is very difficult and is achieved by only a small portion of patients, but he did really great by doing that. What about using the GLP-1s? I think gout is maybe one of the most prominent conditions that we see for which these therapies could be really dramatically beneficial. But we've all had patients on the GLP-1s where the weight comes down and it's miraculous, and then they stop and the weight goes back up and they're on that seesaw.
And I got to thinking about this, discussing it with the father and his son — now my patient also. I really wish that he would be able to do what his dad did and do it without the medications, because I don't know what's going to happen. I know the GLP-1s may have other benefits and may be immunomodulating, and certainly have benefits across a number of diseases not all of which are related to the weight loss. But in this case, because I have seen people rebound, I wonder what would be better in the long run.
Now, you think of other chronic diseases — someone with high blood pressure, we don't tell them, "Well gosh, lose weight and don't eat any salt and your blood pressure will be lower," which it probably would, but we say, "Here, treat with these blood pressure-lowering medications." The same thing with other types of approach to diabetes — we don't tell people to just
you know just do it naturally and that's somehow better than the therapies that we have. But I think it is pause when you think of some conditions for which people have had difficulty maintaining the lifestyle issues that have been healthy to them and proven healthy in larger populations. And so is it the is it the uh journey or is it the destination? I think uh maybe the journey might matter and some journeys might be more successful than others. Although as we're talking about weight I think it is the destination and getting there quick getting a success is I think is important for lots of patients.
So with gout uh it's a condition I think we've known about for a very long time. I think we have great approaches to our patients and now I think we have more ways to approach them including lifestyle but also some of the newer medications. So this is Arty Kavanagh for the gout QD clinics for RheumNow.
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