In this in-depth article we’ve caught up with three of Australia’s leading gout experts to get their view on the best gout research from #EULAR2016 held in London last month.
Four big barriers to treating gout
It may be one of the most common forms of inflammatory arthritis – with research suggesting prevalence in older Australian men is one of the highest in the world – but gout remains a challenging disease to treat effectively.
Persistent stigma, cost of treatment, difficulty tolerating drug therapy and compliance remain four of the biggest barriers, especially in patients who are asymptomatic.
Senior Melbourne rheumatologist affiliated with St Vincent’s Hospital, Dr Michelle Tellus, said many clinicians were unaware that patients could have asymptomatic gout and still have dangerously high levels of serum uric acid.
“There are important co-morbidities to consider with high serum uric acid levels, including renal impairment and cardiac issues,” she said.
Dr Tellus was talking to the limbic after returning from EULAR 2016, and while gout didn’t feature extensively at sessions, there was plenty of discussion about the treatment of patients who were asymptomatic.
“The co-morbidity angle was the main concern with asymptomatic patients,” she said. “We know that cost is an issue and compliance is another problem. When people don’t feel pain they often can’t see why they need to keep taking medication”.
She said that while an episode of gout itself was not a death sentence, the co-morbidities that came with it, in particular renal and cardiac-related problems, needed to be taken seriously by doctors and patients.
“The end result of these co-morbidities can be death,” Dr Tellus said. “What starts out as a sore toe can put them in a coffin.”
She said the growing evidence that some patients can have asymptomatic hyperuricemia highlighted the need to be on the lookout for the disease, particularly in men aged in their 50s.
Dr Tellus believes serum urate testing should form part of other screening for men in this age group, such as prostate, blood pressure, diabetes and cholesterol monitoring.
“If you have a patient who is asymptomatic but has elevated uric acid and borderline serum creatinine, then that would make you consider urate-lowering therapy,” she said.
“And it’s important to remember that even if you get their serum urate level within the normal range, you have to maintain it.”
Gout management in primary care
Dr Tellus said her international colleagues at EULAR also discussed the effectiveness of gout management at a primary care level.
“In general practice, gout is inadequately managed, all over the world, not just in Australia,” she said.
“There was a lot of discussion about education, and how important it is to adequately inform patients before initiating medication. You’ve got to inform them about potential side effects otherwise you’ll never see them again. The drugs are there but it’s getting them to take them and remain compliant that is the challenge.”
Another major hurdle was patients’ hesitation to talk to their doctor in the first place, for fear of what a gout diagnosis might mean.
“Many are embarrassed, thinking that the doctor will think they’re an alcoholic,” she said. “Then there are other patients who self-medicate with over-the-counter drugs such as non-steroidal anti-inflammatory agents to treat their acute attacks. They don’t realise that such treatment can potentially worsen their renal function if not monitored.”
Education is vital, as well as measuring uric acid levels in-between attacks. This can help patients understand the pattern of their disease, and can assist with drug compliance.
“The problem with gout is that once an acute episode resolves it is often forgotten by the patient until the next attack,” Dr Tellus said.
“Gout is a treatable and manageable chronic disease. At the end of the day, gout doesn’t go away by itself – once you have it you always have it and therefore you need to treat gout long-term to prevent functional loss and co-morbidities.”
Australia’s gout rates are among the highest in the world
And it seems there is every reason to keep pushing to improve outcomes for people with gout.
Professor Kevin Pile, Conjoint Professor of Medicine, University of Western Sydney, Director of Medicine and senior rheumatologist at Campbelltown Hospital, said Australian rates were among the highest in the world.
Professor Pile also attended EULAR and said that gout prevalence was discussed at the conference, singling out a Swedish study which quoted the prevalence rate at 1.8% of the population.
New Zealand has the highest prevalence rate in the world at 6%, but he said Australia wasn’t far behind. He cited a recent South Australian article in Internal Medicine Journal which quoted the state’s overall gout prevalence at 5.2%. Males were significantly more likely to have gout than females, and the overall prevalence of hyperuricaemia was 16.6%.
Both gout and hyperuricaemia were associated with male sex, body mass index and renal disease after multivariable adjustment.
Another notable EULAR poster presentation from the Netherlands related to the association between gout and renal impairment.
Professor Pile said researchers found that half of patients with stage four or five chronic kidney disease had gout, without any symptoms or attacks.
“It’s worth being vigilant and checking for gout in patients who have renal impairment but no gout symptoms,” he said.
Skin reactions from drug therapy were another highlight from EULAR for Professor Pile. He said a Spanish retrospective review found that one in five patients who had a previous skin reaction with allopurinol also had a reaction when treated with febuxostat.
“You have to watch them carefully,” he said. “It doesn’t mean you can’t use it, but all prescribing is a balance of risks and benefits, and other treatment options could be considered.”
The problem of non-compliance
Dr Philip Robinson, rheumatologist at the Royal Brisbane and Women’s Hospital, and senior lecturer at the University of Queensland’s Faculty of Medicine and Biomedical Sciences was another of the Australian contingent of rheumatologists at EULAR.
While he said he would have liked to see more gout-related content at EULAR, there were a number of posters and abstracts that were of interest.
The first was an Australian study that looked at how often gout patients reached serum urate target in a rheumatology practice. The researchers found that even in a gout-oriented rheumatology practice, non-compliance was by far the commonest reason for not achieving the serum urate target.
“For compliant patients able to tolerate allopurinol, failure to achieve target was uncommon (4.8%),” they concluded.
“Although potent newer urate-lowering therapies (ULT) are of benefit in specific patients, if advances in ULT availability are going to have a major impact on overall treatment success, they will need to be associated with improved compliance”.
Fellow Australian researchers from Sydney, including Professor Pile, examined the quality of life of patients with gout in south-western Sydney.
They found that the impact of gout was not confined to just physical domains, but had a significant negative impact on psychological health.
Another study, this one out of Denmark, looked at treatment results from a rheumatology clinic.
“Reaching a good treatment result in gout patients still is challenging due to extensive morbidity and co-morbidity,” the authors wrote.
“This study shows that a clinical response can be achieved in the majority of patients when given personalised disease information and long-term follow up with long-term flare prophylaxis in compliance with the EULAR/ACR guidelines.”
“It is suggested that rheumatologists assume the role of following gout patients until they have reached treatment target and clinical remission and subsequently can be followed in general practice.”
A Spanish study assessed the current quality of care in gout patients. The overall improvement in the rate of patients achieving target serum urate over a 6-year period exceeded 50%.
“The rate of gold-standard diagnosis improved, but did not reach the expected outcome,” the authors concluded.
“Interest in recommendations and dedicated crystal arthritis offices were associated with the best results. These preliminary data show for the first time that substantial improvement has been achieved in treat-to-target serum urate levels strategy for gout in the rheumatology community”.
Dr Robinson said that while the conference did not have a large focus on gout, it was always useful to talk face-to-face with specialists who share an interest in the disease.
“Gout is a common problem and the issues are all pretty consistent,” he said. “There are some new treatments in the pipeline as well.”