Better Gout Management Save

Good day, and welcome. My name is John Fitzgerald. I'm from the UCLA and VA, and thank you for tuning in to hear about gout. As a gout researcher, one of my most detested sayings is it's just gout. We know so much about gout, and we have both effective anti inflammatory and urate lowering treatments that many providers, not just rheumatologists, feel that gout is easily managed.

Gout has even been referred to as the curable disease. But unfortunately, it's also one of the most poorly managed diseases. The progression to tafasit and erosive gout is largely preventable, yet we still see patients with advanced disease due to preventable treatment gaps. So briefly on why the curable disease is so rarely cured, adherence is frequently cited, and it is important. But it is also important not to be patient blaming in our management.

The most common reason for stopping urate lowering therapy is that the patient has had a flare and feels like the medication is either not working or making their gout worse, which in a sense it is. For years, I used to try and fight back against the it's just gout mentality. But to patients and their providers, it often is just gout as diabetes, hypertension, hyperlipidemia, cardiovascular disease compete for attention. However, rather than competing with these diseases, gout should be evaluated as part of the metabolic syndrome. Newer, pluripotent medications that treat both gout and the other cardio renal metabolic conditions make the bundling of gout into the metabolic syndrome more practical.

Based on separate studies, both using NHANES' twenty eleven to twenty eighteen data, the prevalence of gout and the metabolic syndrome has been rising. And while gout is not formally part of the metabolic, syndrome definition, gout and metabolic steatosis of the liver are both considered consequences of the insulin resistance syndrome. Mendelian studies have demonstrated that insulin resistance leads to hyperuricemia and gout and not in the other direction. Separate authors using separate day bay databases came to the same conclusion, looking at SNPs looking at, genetic SNPs associated with insulin and type two diabetes were associated with URA outcomes, but not in the reverse. These other also showed the same findings.

In addition to cardiovascular disease being part of the metabolic syndrome, the inflammatory pathway associated with gout is an important independent risk factor. As a reminder, several studies demonstrated that treatment with anti inflammatories loaded cardiovascular risk. These included methotrexate, canakinumab, and importantly, colchicine. Treatment with colchicine lowered cardiovascular disease risk leading to an FDA indication for the prevention of cardiovascular disease. And it should be noted that during these trials, while there were high reports of GI side effects, there were no significant myopathies despite ninety five percent of patients on concurrent statin therapy.

However, despite the indication, uptake of colchicine for cardiovascular disease has been slow, but the indication has lowered my threshold for preference in colchicine in managing our patients with gout. An important 2022 study found that cardiovascular risk increased in the first sixty days after a gout flare before returning to baseline levels after a hundred and eighty days. As mentioned, gout and the metabolic and and metabolic steatosis liver disease are both manifestations of the insulin resistance syndrome. The association between fructose intake and hyperuricemia likely further contributes to fatty liver disease. Switching now to therapies.

The SGLT the SGLT II medications have shown benefit in many cardio renal metabolic conditions, and there are several direct benefits for patients with hyperglycemia and gout. To highlight a few key therapeutic points in managing gout, when starting ULT, discuss anti inflammatory options with your patients. These can include daily prophylaxis, pill and pocket strategies, or start low and go slow, urate lowering titrations. This is the original febuxostat slow titration schedule that has been updated with an allopurinol titration schedule. Interestingly, in this study, even after six months of low dose colchicine, a small flare in in a small spike in gout flares was noted at six months.

Finally, allopurinol titration is impacted by starting dose and dose needed to get serum urate less than six milligrams per deciliter. This easy allo dosing schedule was developed by New Zealand researchers, and they developed this target dose chart. You'll note that body weight has a significant impact on final target dose as does starting, urate levels. Renal function surprisingly has little impact. So the recommendations for dose to target would be start low, hundred milligrams lower in patients with renal disease, and titrate up to the target and then check a urate.

And then you could titrate up or down. Doses should be lowered for patients with renal disease. An even easier allo dosing schedule is to consider you need about a hundred milligrams for every one milligram per deciliter of change needed. The starting dose of allopurinol is important also. We start low to limit the risk of allopurinol hypersensitivity syndrome, and this is available in the data.

And finally, we have gout patient education, programs available online, at the UCLA and the Greater Los Angeles VA Rheumatology websites. Thanks again for tuning in. And to hear more about gout, check out RheumNow.

Hello, everyone. My name is Kennen, and I'm based in Bangkok, Thailand. Today, would like to talk about gout flares during hospital stay, how to predict them, and how to manage them effectively. But first, why should we care about in hospital gout flares? Well, there are several reasons.

Studies have shown that in hospital gout flare usually increases hospital length of stay by several days, maybe three or six days. And this translates into a negative patient experience, additional investigations, and increased health care costs. Unfortunately, gout flares tend to happen quite frequently during hospitalization due to several factors. First, patients who are who have uncontrolled gout are particularly vulnerable. These include patients who are not taking urate lowering therapy before admissions, those with high baseline serum urate before admissions, and those with clinical tofers.

Additionally, during hospital stay, these patients are also exposed to several additional triggers of gout flare, such as, you know, major surgery, diuretics therapy, kidney injury, and quite frequently, some interruption of urate lowering therapy that they have been taking before hospital's admission. So all of these factors together will cause destabilization of uric crystals, crystal shedding, and enhanced inflammatory response, ultimately leading to gout flares. So I think it is very important to identify patients with these risk factors as soon as possible. Well, ideally at the time of hospital admission. The easiest thing that I would do is that I would identify patients with a known history of gout on the very first day of hospital admission, and then I will look for evidence of uncontrolled gout, you know, such as physical tofers, high baseline serum urate levels, or preadmission serum urate levels, and especially absence of urine lowering therapy before admissions.

Generally speaking, patients with greater number of risk factors will mean that they are at greater risk of develop developing gout flare down the line. So what should we do about these high risk patients? Well, the first and probably the most important thing is that if a patient has already been taking ura lowering therapy before hospital admission, it is very important to make sure that these therapy are continued throughout their hospital stay, unless there is clear contraindication. And secondly, we might want to pay extra attention to patients who are planning to undergo major surgery or those who are started on diuretics or those with kidney failures or heart failures. You know, if these patients suddenly develop joint pain or unexplained fever, then gout flash should be very, very high on the list of differential diagnosis.

And this early recognition of gout flare will allow us to take immediate actions against this inflammatory response and maybe help reduce negative consequences of gout flare. Also, I think in many cases, you know, early identification of high risk patients during hospital stay maybe may help us prevent unnecessary septic workup or inappropriate antibiotic use in case of gout flares. I also want to point out one one positive aspect of in hospital gout flare, because sometimes, in some cases, inpatient setting is a pretty good opportunity to discuss long term urate lowering therapy with the patients. Because hospital setting, in this setting, we often have more time to talk to the patients and even involve family members during the discussion. And, you know, many patients, you know, after they have just recovered from a painful gout flare episode during their hospital stay, you know, they might be more motivated to take, you know, actions to get their gout under control in the long run.

So seeing patients in hospital based context, in inpatient context, may allow us to start or optimize long term gout therapy. So this kind of opportunities can be quite rare in the outpatient setting, because we all know that gout patients tend to self medicate and they would rather self medicate than seek medical attention. So I think overall, right now, what we can do is to we should recognize which patients are at risk and then try to take preventive actions or at least make sure that we are ready to diagnose and treat gout flares during hospital stay where possible. Well, thank you very much. That will be all.

Hello, everyone. I'm Doctor. Richard Conway from Dublin, Ireland. And I'm here to talk to you today as part of RheumNow's gout campaign. And I'm going to talk to you today about bespoke telehealth in gout, a missed opportunity.

Telehealth is something I do. I love doing it. I think it allows great flexibility and opportunities for us and for our patients. But I don't think all of you really do it. I think we, as rheumatology as a specialty, we did do telehealth.

We did lots of us. We had to during COVID. And then after COVID, we kind of just slowly or not so slowly went back into our old habits. And I think for some patients, absolutely telehealth was a step too far. It was too technically challenging.

They just couldn't really cope with the interaction with their clinicians that way. But I think that was probably a relative minority of patients. I think there were kind of a similar sized minority who found telehealth fantastic and continue to find telehealth fantastic and are very, very they much prefer doing it. It gives them the opportunity to build their appointments into their daily work life balance type thing, and they're not having to take half a day off work to come into their appointment. And then I think the majority of people probably don't really care one way or another.

They both work for them. And sometimes face to face appointments are better, sometimes telehealth is better. Perhaps it might depend on what their actual appointment is about, which they prefer. So I think there's a huge opportunity there that we're not utilising to give better flexibility and better choice to our patients. And I think it does depend a little bit on the disease.

And we are here talking about gout. And I think gout is probably one of the best cases for something that should be done by telehealth. And I think probably a lot of people are acting like, what? We want gout, we want to be seeing this, we need to see that it actually is gout and examine it. We need to put a needle into it and take some crystals out and whatever else, maybe inject the joint.

But actually, yes, that's true, but that is a very small minority of what we actually do with gout or what we should be doing with gout. We see those people maybe during an acute flare in our clinics, or we see them as an inpatient consult, but most of the work of gout is not dealing with that group of patients. It's dealing with people who are not flaring at the minute and they need their gout managed better. And perhaps we feel a greater proportion of our work is more to flares because we're not doing the other stuff good and we're not seeing people back as frequently or as thoroughly as we should for gout. The other things about gout, I like treating gout.

I love my gout patients. They're great people. But with the best will in the world, people with gout are not good at coming into clinic. Their follow-up rate is not good for all sorts of reasons. They're often relatively young people with busy lives.

If they're feeling well, they'll often put their appointments on the back burner, especially when they're doing well. They are not the most adherent for similar reasons, either to their appointment schedule or to their medications. So I think there is huge value in offering these people more flexibility. And if also a case of, Oh, I forgot my appointment, but actually I can just do it over telehealth right now. I can just step into an empty room or into my car and do it there.

Anywhere that's quiet, we can do this five minute appointment and keep our management of the gout on track. So I think the gout patients had poor attendance, poor adherence, both factors that are potentially amenable with telehealth. I think it's hugely important with patients who have gout that we're constantly reinforcing the messages of the need to take their medication, how to take their medication, because it can be confusing. They're often on a couple of different things, a urate lowering therapy and maybe some colchicine or something else, maybe something else again, if they're having a flare. So there's a lot of moving parts here.

Again, another factor is that gout patients, their visits, especially when they're doing well, are quick. So it might be five or ten minutes. It's very quick, something that's very easily doable over telehealth and that can be then allowed to be fit into someone's day like this. When we're starting someone on urate lowering therapy, either for buxastat or particularly with allopurinol, there's a lot of dose titration going on. We're starting the medication, repeating the blood test in about four weeks.

We're then potentially increasing the dose up. And all of that doesn't happen naturally. It has to happen in a clinic appointment. And why can't that be done over the belly else? Literally all we're doing is checking the bloods, seeing if they're good enough or not, probably increasing up the urate lowering therapy until we reach a target.

Something quick and easy to do over telehealth. Likewise, if we have somebody on colchicine prophylaxis as they are titrating up their urate lowering therapy, then that is also something which is stopping at some point. And the stopping or reduction of that is something that's best done in a controlled fashion. I have often told patients that, Oh, we'll do this for six months and then stop us. Nobody remembers.

It has to be sent at the time it's meant to stop or it just won't happen. I think we have been neglecting our patients in some ways due to these kind of combination of issues. And we kind of have an attitude of, Oh, if the patient isn't bothered showing up about their gout, sure, What can we do? That's just how gout patients are. We'll just see them the next time they flare and try again.

And I don't think that's good enough. I think we should be more proactive about this, to be utilising telehealth to manage gout and improving our patients' lives and longer term outcomes. Feel free to agree with me, feel free to disagree with me, give out to me on Twitter or on RheumNow. But I think we're really missing a trick with our lack of adoption of telehealth, in particular in Gouch. I'm Doctor.

Richard Conway, and check out RheumNow for all the content on this gout campaign.