step-up prescription of the doses of urate-lowering
medications, or absence of prophylactic treatment.
Some patients may need high doses of
medications that are not commonly prescribed
in primary practice (such as allopurinol at
doses exceeding 300mg/day), combination of
medications (such as XOIs and uricosurics), hospital/
specialist prescriptions (such as canakinumab or
benzbromarone), use of off-label doses (febuxostat
120 or 240mg/day) or off-label indications (anakinra).
Also, presence of comorbidities such as advanced
chronic kidney disease, chronic heart failure, or
solid organ transplant, might be situations in which
specialised consultation is required.
patients with longstanding disease (Figure 1).
Elderly patients with arthritis may show both
chondrocalcinosis and hyperuricaemia, making it
difficult to differentiate clinically gout from acute
pyrophosphate arthritis, also known as ‘pseudogout’
(Figure 2).
Other patients might present psoriatic skin
lesions, hyperuricaemia, and symmetrical
involvement of the joints of the lower limbs that can
make it difficult to differentiate gout from psoriatic
arthritis.
In such cases, aspiration of the current or
a previously involved joint may be useful to visualise
urate crystals in synovial fluid, along with some
imaging modalities, when indicated.
Figure 2
The presence of X-ray
chondrocalcinosis may
hamper the diagnosis of
acute arthritis in patients
with hyperuricaemia;
in this patient, both
calcium pyrophosphate
and urate were observed
in synovial fluid
(Oxford) 2018;57(suppl_1):
i20–i26.
6 Kiltz U et al. Treat-to-target
(T2T) recommendations for
gout. Ann Rheum Dis 2016;
76(4):632–8.
7 National Institute for Health
and Care Excellence. Appraisal
consultation document.
Lesinurad for treating chronic
hyperuricaemia in people with
gout. www.nice.org.uk/guidance/
ta506/documents/appraisal-
consultation-document
(accessed Septemebr 2018).
8 Khanna D, et al. 2012 American
College of Rheumatology
guidelines for management
of gout. Part 1: Systematic
nonpharmacologic and
pharmacologic therapeutic
approaches to hyperuricemia.
Arthritis Care Res (Hoboken)
2012;64(10):1431–46.
9 Hui M et al. The British
Evaluation and control of comorbidities
Patients with gout commonly show a variety of
comorbid conditions, including hypertension,
adult-onset diabetes, and hyperlipidaemia.
These conditions are major risk factors for the
development of cardiovascular events, most of
which are managed by the primary care team.
The presence of comorbid conditions that might
need periodic specialised evaluation, such as chronic
kidney disease or chronic heart failure, will require
coordination between health care providers in order
to provide timely and cost-effective interventions.
Conclusions
In summary, most patients with gout are evaluated
and treated in primary care. Here is where the bases
for success are determined, with additional support
for diagnosis, evaluation, and treatment, if needed.
Collaboration between primary and secondary care
is presumably more fruitful in selected clinical
scenarios, mostly involving complex patients.
Difficult treatment
In some instances, ‘difficult to treat’ gout may be a
cause for referral to a rheumatologist. In such cases,
a certain diagnosis would be preferable to ensure
that lack of response to treatment is not caused
by misdiagnosis. Also, the lack of clinical response
might be caused, as mentioned previously, by lack of
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