HPE Grunenthal handbook - Page 10

table 2 Phenotypes of gout patients 1 MTP1 arthritis in a young male No comorbidity Positive family history due to low fractional clearance of urate* Step 1 Often just NSAID offered Steps 2–3 XOi: Allopurinol 100–300mg daily 2 MTP1/ankle/knee arthritis in older male or atypical arthritis in older female Obesity/hypertension/ hyperlipidaemia in many/ DM in many: Cardiovascular risk score high Steps 2–3 Will need XOi: allopurinol escalation regime 3 MTP1/ankle/knee arthritis in older male Low fractional clearance of urate and obesity due to lifestyle/hypertension/ hyperlipidaemia in many/DM in many: Cardiovascular risk score high Steps 1–3 Will need personalised treatment with high-dose XOi or XOi+US: two MoAs 4 MTP1/ankle/knee arthritis in older man Diminished clearance: glomerular filtration rate <50 Low fractional excretion of urate Often advanced stage with tophi Step 1 Will need redefining the personal target for treatment depending also on feasibility 5 Gouty arthritis in young females/ hereditary syndrome Females with hypertension and/or obesity; sporadic attacks Step 1–2 Personalised treatment MTP1, metatarsophalangeal one; XOi, xanthine oxidase inhibitor; US, uricosuric; MoA, mode of action *Fractional clearance of urate is a marker of how efficiently urate is being reabsorbed/excreted; average normal value in men is 7.5% and 4.5% in gout (although some gout patients can have very low levels (1.5–2.0%)) of 17% of all gout patients were in Cluster 2 and these were only obese; 24% in Cluster 3 had diabetes and 1 in 3 with liver disorder (39%) plus excessive alcohol use; 28% in Cluster 4 had dyslipidaemia and hypercholesterolaemia without cardio-renal disorders or hepatic disorders; 18% in Cluster 5 with combined coronary heart disease and heart/renal failure and often using diuretics. Cluster 5 was about 10 years older and consisted of more women in 28% and minimal alcohol consumption. Such clusters do not provide an epidemiologic insight of comorbidity, but do not help us in clinical practice. In this article, we describe patient journeys and case studies in five separate identifyable phenotypes. Clearly an arthritic patient can be treated for quite some time with just intermittent NSAIDs or prednisolone in cases of attacks presenting to the general practitioner (GP). With crystal proof, urate-lowering treatment (ULT) is usually initiated at the second or third attack. In the third step, GPs either themselves initiate ULT (XOI) or refer to a specialist; factors involving this decision are GP- as well as patient-dependent and also dependent on numbers of comorbidities. An important factor is the intrinsic motivation for chronic causative treatment as well as adherence to improved lifestyle, versus short-term therapy focusing solely on the attack. Often forgotten as a factor is the rapid availability of specialised care. Altogether, it might take some time before the patient reaches stage 4, that is, a negative urate balance. In step 5, networks of cooperative care with specialists and GPs enable patients to be treated for chronic continuation of ULT in the periphery of care systems. 4 The optimal patient journey should be chosen by patients and physicians. 5 Case studies Some real-life gout patient phenotypes and patient journeys as presented to our department are described in the following case studies. Case study 1 A healthy 40-year-old man with a family history 10 | 2018 | hospitalpharmacyeurope.com Intrinsic motivation is needed for an improved lifestyle and, if required, ULTs of gout (father had gout) and a three-year period suffering from an annual gout attack in his big toe, often presenting during the night. After the last attack, about six months prior, he suffered from recurrent flares that responded to colchicine and/or prednisolone but the attacks still recurred. He had initiated a healthier lifestyle through participating in sports and drinking malted beers instead of regular beer. He wanted to know how to prevent the distressing attacks. Physical examination Healthy man with BMI 21.2 with some residual redness over both MTP1 joints at both sides Ultrasonography Double contour sign left-sided MTP1 with grade 1 power Doppler X-rays forefeet Slight degeneration with a subcortical cyst. The Gout Calculator scored 11.5 points: highly suggestive of gout regarding sensitivity and specificity. Laboratory test serum urate (SUA) 440μM (7.4mg/dl) with glomerular filtration rate >60; serum creatinine 90 ESR 2 and CRP<1,0; haemoglobin 8.6mM and urate excretion 4.3mM (72.28mg/dl); fractional clearance of urate (FCU) 4.3% Course Dietary advice (reduce purine ingestion/ stop malted beer and increase coffee intake; only 100g of meat daily) with colchicine 0.5mg twice daily. This resulted in a slight improvement but his complaints in feet remained as did his double contour on ultrasongraphy (US) two months after the initial measurement. Urate-lowering treatment was started (allopurinol 300mg daily with a significant improvement within 4 months; SUA dropped to 250mmol/l (4.2mg/dl). The double contour also disappeared. From such cases, it is shown that most diets are enriched with calories and purines, and specific families (genetic factors) with a lower urate clearance due to urate transporters might be prone to develop a urate accumulation syndrome resulting in monosodium urate (MSU) deposits on the