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 hospitalpharmacyeurope.com | 2018 | 13