Predicting and Managing Gout Flares in Hospitalized Patients Save

Hello everyone. My name is Canon and I'm based in Bangkok, Thailand. Today I 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 flares usually increase hospital length of stay by several days — maybe three or six days — and this translates into a negative patient experience, additional investigations, and increased healthcare cost.

Unfortunately, gout flares tend to happen quite frequently during hospitalization due to several factors. First, patients who have uncontrolled gout are particularly vulnerable. These include patients who are not taking urate-lowering therapy before admission, those with high baseline serum urate before admission, and those with tophi. Additionally, during hospital stay, these patients are also exposed to several additional triggers of gout flare, such as major surgery, diuretic therapy, kidney injury, and quite frequently some interruption of urate-lowering therapy that they have been taking before hospital admission. So all these factors together will cause destabilization of uric acid 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 — ideally at the time of hospital admission. The easiest thing that I would do is identify patients with a known history of gout on the very first day of hospital admission, and then I would look for evidence of uncontrolled gout, such as tophi, high baseline serum urate levels or pre-admission serum urate levels, and especially absence of urate-lowering therapy before admission. Generally speaking, patients with a greater number of risk factors will be at greater risk of developing a 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 urate-lowering therapy before hospital admission, it is very important to make sure that this therapy is continued throughout their hospital stay unless there is a 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 failure or heart failure. If these patients suddenly develop joint pain or unexplained fever, then gout flares should be very high on the list of differential diagnosis. This early recognition of gout flares will allow us to take immediate action against this inflammatory response and may help reduce the negative consequences of gout flares. Also, I think in many cases early identification of high-risk patients during hospital stay may help us prevent unnecessary septic workup or inappropriate antibiotic use in cases of gout flares.

I also want to point out one positive aspect of in-hospital gout flares, because in some cases the inpatient setting is a pretty good opportunity to discuss long-term urate-lowering therapy with patients. In the hospital setting we often have more time to talk to patients and even involve family members in the discussion, and many patients, after they have just recovered from a painful gout flare episode during the hospital stay, may be more motivated to take actions to get their gout under control in the long run. So seeing patients in an inpatient context may allow us to start or optimize long-term gout therapy. This kind of opportunity can be quite rare in the outpatient setting, because we all know that outpatients tend to self-medicate rather than seek medical attention.

So I think overall, what we can do right now is 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.