Optimising treatment
The patient journey
and optimising treatment
Patients often only present to specialised care at an advanced stage, and then only a few
treatment options remain, so the earlier GPs are involved in the patient journey, the more
options for individualised pharmacotherapeutic regimens there will be
Tim Jansen MD PhD
Matthijs Janssen MD PhD
VieCuri MC, Venlo,
The Netherlands
Gout is a highly prevalent disorder in the
general population and in rheumatology
practices. Its pathophysiology is based on
monosodium urate accumulation and on activation
of the inflammasome, which results in an auto-
inflammatory syndrome. Gout predominantly affects
males, but it might also affect females, particularly
after menopause. 1 Serum urate concentrations in
patients (normal value in females: 0.12–0.34mmol/l
(2–6mg/dl) and males: 0.20–0.42mmol/l (3–7mg/dl))
vary greatly, with a diurnal and annual rhythm. The
urate level is a result of genetic predisposition and
environmental factors, and the presence of
comorbidities such as cardio-renal diseases, diabetes
mellitus and the metabolic syndrome.
Hyperuricaemia is an elevated serum urate
concentration above normal limits and is associated
with gout. Gout is associated with sleep apnoea
syndrome, non-alcoholic fatty liver disease,
congestive heart disease, stroke and
hyperlipidaemia. Gout is not only an unpleasant
or invalidating disease but is also associated with
premature cardiovascular death and probably
increased death due to cancer and infectious
diseases. Data from the USA categorised gout
patients into groups, with hypertension in 74% of
patients, chronic kidney disease (stage 2 or more)
in 71%, obesity in 53%, diabetes in 26%, and heart
failure in 11%. 2 Aggregation of comorbidities in gout
is common but complex. Cluster analysis in a French
gout population of over 2750 patients revealed
a similar picture. This study divided the patients into
five different clusters with, interestingly, Cluster 1
comprising 12% of the total French gout population
and consisting of only males with neither
comorbidities nor cardiovascular disease. 3 A total
table 1
Gout subdivided into phases in a patient journey and potential actions taken
General practitioner Rheumatologist
0 Asymptomatic hyperuricaemia No actions/considerations No actions/considerations unless
high cardiovascular risk, then lifestyle
advice
1 First arthritic attack
Metatarsophalangeal joint
Ankle
Knee NSAIDs; most frequently diclofenac Obtain crystal proof and dietary advice
with five days prednisolone
2 Second arthritic attack NSAID/colchicine/ five days prednisolone
scheme (any inflammasome inhibitor) Prednisolone/colchicine scheme plus
XOI
3 Third and following arthritic attack or
ongoing attack and/or in between gout
arthropathy with double contour at
ultrasonography
Tophaceous accumulation NSAID/colchicine /prednisolone scheme;
Consider: referral to rheumatologist or
start XOI [any inflammasome inhibitor
plus ULT?]
ULT indicated if two attacks within one
year OR tophi Consider: Prednisolone and/colchicine
scheme with escalating dose XOi
4 Negative urate balance with potentially
some short attacks Treatment focusing on attack rate
annihilation Personalised XOI and/or US aiming for
pre-defined target
5 Debulked and on stable low serum urate
levels, lacking attacks Continue chronic ULTs Continue chronic ULT aiming at serum
urate <360 micromolar (<6mg/dl)
Consider stopping ULT when the patient
is in complete remission
(first-choice NSAID etoricoxib or
naproxen)
Consider: interleukin-1 blockade when
NSAID/colchicine/prednisolone are
failing
XOi, xanthine oxidase inhibitor (allopurinol/febuxostat); ULT, urate-lowering therapies; US, uricosuric (benzbromarone/ lesinurad/ probenecid)
hospitalpharmacyeurope.com | 2018 | 9