New management tactics emerge for patients with difficult-to-treat gout

DESTIN, Fla. — Emerging methods of care could improve the management of difficult-to-treat gout, according to a speaker at the Congress of Clinical Rheumatology Annual Meeting, here.

In his presentation, Robert Keenan, MD, MPH, assistant professor of medicine in the Division of Rheumatology and Immunology and director at the Duke Gout and Crystal Arthropathy Clinic, defined difficult-to-treat gout as occurring in patients who do not tolerate most treatments for acute attacks or urate-lowering therapy (ULT), but have persistent attacks. Patients who do not respond to maximal ULT with a serum uric acid (sUA) level of greater than 6 mg/dL; patients with visible tophi, low sUA and persistent attacks; and patients with persistent attacks who are not on maximal ULT and have high sUA can be considered as having difficult-to-treat gout, Keenan, who is also the medical director at the Duke Specialty infusion Center at the Duke University School of Medicine, said.

“But not only do we want to define difficult-to-treat gout, we want to acknowledge the consequences of under-treating gout patients. We need to open a discussion on current and emerging treatment strategies of acute and chronic gout.”

Following a series of individual case studies, researchers found corticosteroids can be an effective treatment for difficult-to-treat gout. Adrenocorticotropic hormones, colchicine, febuxostat, ulodesine, arhalofenate and interleukin-1 inhibitors, such canakinumab, could also be effective therapies, he noted.

“For attacks of gouty arthritis, initiate pharmacotherapy immediately and continue ULT during flares,” Keenan said, adding that rheumatologists should consider a combination therapy of xanthine oxidase inhibitors and uricosuric in patients when sUA is not achieved.

“The main goal is to carefully consider comorbidities and concomitant medications when choosing therapy,” Keenan said. “Base therapy on reaching ULT target in the context of tophaceous burden and disability. The lower, the better for many patients.” – by Shawn M. Carter

Reference:

Keenan R, et al. Management of difficult-to-treat gout patients. Presented at: Congress of Clinical Rheumatology Annual Meeting; May 12-15, 2015; Destin, Fla.

Disclosure: Keenan reports he is on the scientific advisory board of AstraZeneca, and the data does include mention of pipeline or investigational medications and off-label use of medications or medical devices.