HPE Grunenthal handbook | Page 13

General practice
The general practitioner’s
approach to gout
Although most patients with gout are evaluated and treated in primary care, collaboration
between primary and secondary care can be fruitful in selected clinical scenarios, mostly
involving complex patients
Fernando Perez-Ruiz
MD PhD
Estibaliz Andrés
Trasahedo MD
Sandra P Chinchilla MD
Hospital Universitario
Cruces, Vizcaya, Spain
Gout is the most common inflammatory
arthritis in adults. Its prevalence has increased
in developed countries along with life expectancy,
as well as comorbid conditions and treatments that
may favour the development of hyperuricaemia, and
therefore gout. 1 Primary care providers care for most
gout patients and their contribution to the proper
diagnosis, evaluation, and control of the disease is
therefore of the utmost importance.
Practical approach to the diagnosis of gout
Gout usually has a typical presentation:
sudden, asymmetrical, acute arthritis of the
first metatarsophalangeal joint or tarsal joints,
commonly associated with local erythema. 2 In
patients with previous longstanding hyperuricaemia
and a typical presentation, clinical diagnosis is
mostly accurate. Most primary practices, and even
specialised ones, may lack personnel, experience,
time, or resources to consider microscopy-based
diagnosis or ultrasonography evaluation. Indeed,
even in hospital-based, specialised practice, only
one third of patients have gold-standard diagnosis. 3
Therefore, a practical approach is to rely on
clinical diagnosis for the typical presentation,
and seek diagnostic support in cases with atypical
presentations, unusual histories or inadequate
responses to adequate treatment.
Evaluation of the gouty patient
Causes of gout
The development of clinical manifestations of gout
might raise the need to investigate the causes of
hyperuricaemia: in addition to lifestyle; medications,
chronic kidney disease, and haematologic disorders
should be considered in the older population. Other
diseases are uncommon, and most evaluations can
be performed with basic, inexpensive analyses.
Severity of gout
There is no overall accepted definition of severe
gout. Nevertheless, it seems plausible to consider
that patients who suffer frequent flares, show
extensive urate deposition (multiple tophi or
assessed by imaging studies), or develop structural
joint damage might be considered as suffering
severe gout. Clinical history, physical exam, and
plain X-ray evaluation, if needed, might be sufficient
to evaluate the severity of gout in most cases.
Comorbidities
Gout is commonly associated to comorbid
conditions such as obesity, hypertension, diabetes,
chronic kidney disease, and cardiovascular
disorders. Morbidity and mortality in gout are
mostly derived from cardiovascular risk factors and
cardiovascular events. Therefore, diagnosis of gout
is an opportunity to make a reappraisal of such
conditions and consider specific interventions if
applicable.
Treatment
Indication and targets
Treatment of gout is always indicated, considering
treatment as any intervention, not necessarily
pharmacological, to correct the pathophysiological
mechanisms causing disease. Lifestyle changes,
if applicable, such as implementing a healthy
diet, exercising, and smoking cessation, 4 are to be
considered, mostly as a contribution to general
health and specifically to prevent the risk of
suffering cardiovascular events in the future. The
overall impact of lifestyle changes in serum urate
is mild to moderate in most cases. Therefore, urate-
lowering medications must be considered in most
patients.
A treat-to-target strategy for the treatment of
hyperuricaemia in gout has been considered during
the last decade 5 and endorsed by a multinational
group of experts. 6 This approach is similar to those
for hyperlipidaemia, hypertension, and diabetes,
all of which are therapeutic approaches familiar
to general practitioners.
Different therapeutic serum urate (sUA) targets
have been considered and recommended, and even
endorsed by agencies 7 and experts to reduce the
rate of flares and debulking tophaceous deposits.
Whereas a general target of <6mg/dl (0.36mmol/l) is
considered, a lower target of <5mg/dl (0.30mmol/l)
is advised for patients with severe gout, 4,8 and in UK
guidelines. 9 Once again, the approach is similar to
that for hypercholesterolaemia 10 depending on the
existence of a previous cardiovascular event.
Urate-lowering medications
Urate-lowering medications are indicated when
general measures are not sufficient to reach
the desirable therapeutic sUA target. Several
recommendations arise from different groups of
experts: while the American College of Physicians
does not support early treatment, 11 the EULAR
updated recommendations suggest discussing the
convenience of early treatment with the patient,
especially in those with a high risk of developing
severe gout. 4 Other groups adopt an intermediate
position, with indication of urate-lowering
medications in patients with structural damage,
recurrent flares, presence of tophi or comorbidities,
such as chronic kidney disease. 8,9
Different medications are available within
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