To treat gout properly, continue treatment after the attack![1]
Press release from the French Academy of Medicine
October 22, 2024
Gout unfortunately has the image of a self-inflicted disease, without gravity and deserving little attention. This image must be corrected, because this disease with a genetic component becomes severe, with a possible early overmortality when not treated in the long run, even though it benefits from highly effective treatments. Attention to gout attacks often makes us forget that gout is also a chronic disease.
International mobilization is currently increasing, so that the public health challenge of gout is better considered (1), risk factors are better controlled, diagnosis is made earlier and adherence to treatment strengthened (2).
In France, gout affects 0.9% of the population, more than 500,000 adults, with an over-representation of men. It is the most common type of arthritis.
Overweight, alcohol and purine-rich foods, and a genetic predisposition are the main factors behind years of elevated uric acid levels in blood (hyperuricemia), and the deposition of sodium urate microcrystals in the joints. If attacks resolve spontaneously within one to three weeks, or more rapidly on treatment, allowing deposits to accumulate leads to infiltration and destruction of the joints causing permanent disability. During or after attacks, myocardial infarction or stroke occurs in 3-4% of cases, probably due to acute inflammation. Gout is also associated with obesity, hypertension, type 2 diabetes and dyslipidemia, which further increase cardiovascular risk and the risk of premature mortality.
The excess of uric acid in the blood is reversible. Its reduction to less than 50 mg (300 mmol)/L is achieved by early prescription of hypo-uricemic drugs, long-term maintenance of controlled uricemia with a diet that limits alcohol and unadvisable foods, and fighting overweight (3, 4).
Despite the efficacy of hypo-uricemic treatment, persistent gout attacks are frequent and result from an imperfect treatment management due to : insufficient prescribing, notably due to the fear of serious allopurinol-related cutaneous accidents, which are however rare and widely prevented by a gradual dose introduction (3); the absence of target uricemia (5) ; and above all, poor adherence to treatment, gout being the chronic disease in which adherence to treatment is the lowest (6), which underlines the importance of patient information and therapeutic education, necessary for a good understanding of the disease and its treatment (7), as well as the application of international recommendations (8).
Considering the high prevalence, health and social consequences and complications of gout, the French Academy of Medicine underlines that an appropriate treatment of gout remains a major public health challenge. It points out that facing it successfully requires the following rules:
– Hypo-uricemic treatment as soon as diagnosis is certain, targeting a serum level below 50 mg/L (300 mmol/L), with small doses of colchicine during the first 6 months of treatment and allopurinol introduced gradually and increased by steps according to the level of renal function;
– Monitoring uricemia to adjust treatment dosage and continued even after signs of gout have disappeared, due to the risk of recurrence of signs and the onset of complications in the event of discontinuation;
– Dietary advice and drastic reduction in alcohol consumption;
– A patient information and therapeutic education program, essential for long-term adherence and successful treatment.
References
1– GBD 2021 Gout Collaborators, Cross M. et al., Global, regional, and national burden of gout, 1990–2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology, 2024, 6, 8, e507 – e517.
2– Latourte A., Pascart T., Flipo R.M. et al., Recommandations 2020 de la Société française de rhumatologie pour la prise en charge de la goutte : traitement des crises de goutte. Revue du Rhumatisme, 2020, 87, pp.324 – 331. https://hal.science/hal-03493571
3– Pascart T., Latourte A., Flipo R.M., et al., Recommendations from the French Society of Rheumatology for the management of gout: urate-lowering therapy. Joint Bone Spine, 2020; 87:395-404.
4– Kuo C.F., GraingeJ., Mallen C., et al., Eligibility for and prescription of urate-lowering treatment in patients with incident gout in England, JAMA, 2016; 312:2684-6.
5– Maravic M., Hincapie N., Pilet S., et al., Persistent clinical inertia in gout in 2014: An observational French longitudinal patient database study. Joint Bone Spine, 2018; 85: 311–315.
6- Reach G., Treatment adherence in patients with gout, Joint Bone Spine, 2011; 78: 456-9.
7– Doherty M, Jenkins W., Richardson H., et al., Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomized controlled trial, Lancet, 2018; 392:1403-12.
8– Bardin et al., Apport des recommandations internationales sur le traitement hypo-uricémiant de la goutte Bull Acad Natl Med, 2022 ; 206 :825-30
[1] Press release from the Academy’s Rapid Communication Platform.