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Michael TJF, Chan JS, Hughes S, Wright DFB, Coleshill MJ, Hughes DA, Day RO, Aslani P, Stocker SL. The experiences and perspectives of people with gout on urate self-monitoring. Health Expect 2024; 27:e14071. [PMID: 38742836 PMCID: PMC11092534 DOI: 10.1111/hex.14071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Gout management remains suboptimal despite safe and effective urate-lowering therapy. Self-monitoring of urate may improve gout management, however, the acceptability of urate self-monitoring by people with gout is unknown. The aim of this study was to explore the experiences of urate self-monitoring in people with gout. METHODS Semistructured interviews were conducted with people taking urate-lowering therapy (N = 30) in a 12-month trial of urate self-monitoring in rural and urban Australia. Interviews covered the experience of monitoring and its effect on gout self-management. Deidentified transcripts were analysed thematically. RESULTS Participants valued the ability to self-monitor and gain more understanding of urate control compared with the annual monitoring ordered by their doctors. Participants indicated that self-monitoring at home was easy, convenient and informed gout self-management behaviours such as dietary modifications, hydration, exercise and medication routines. Many participants self-monitored to understand urate concentration changes in response to feeling a gout flare was imminent or whether their behaviours, for example, alcohol intake, increased the risk of a gout flare. Urate concentrations were shared with doctors mainly when they were above target to seek management support, and this led to allopurinol dose increases in some cases. CONCLUSION Urate self-monitoring was viewed by people with gout as convenient and useful for independent management of gout. They believed self-monitoring achieved better gout control with a less restricted lifestyle. Urate data was shared with doctors at the patient's discretion and helped inform clinical decisions, such as allopurinol dose changes. Further research on implementing urate self-monitoring in routine care would enable an evaluation of its impact on medication adherence and clinical outcomes, as well as inform gout management guidelines. PATIENT OR PUBLIC CONTRIBUTION One person with gout, who was not a participant, was involved in the study design by providing feedback and pilot testing the semistructured interview guide. In response to their feedback, subsequent modifications to the interview guide were made to improve the understandability of the questions from a patient perspective. No additional questions were suggested.
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Affiliation(s)
- Toni J. F. Michael
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Jian S. Chan
- St Vincent's Clinical School Campus, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
| | - Stephen Hughes
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Daniel F. B. Wright
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- St Vincent's Clinical School Campus, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
| | - Matthew J. Coleshill
- Black Dog Institute, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
| | - Dyfrig A. Hughes
- Centre for Health Economics and Medicines Evaluation, North Wales Medical SchoolBangor UniversityWalesUK
| | - Richard O. Day
- St Vincent's Clinical School Campus, Faculty of MedicineThe University of New South WalesSydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
| | - Parisa Aslani
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Sophie L. Stocker
- School of Pharmacy, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalSydneyNew South WalesAustralia
- Sydney Infectious Diseases Institute, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Sydney Musculoskeletal Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Christensen R, Zobbe K, Nielsen SM, Stamp LK, Henriksen M, Overgaard AF, Dreyer L, Knop FK, Singh JA, Doherty M, Richette P, Astrup A, Ellegaard K, Bartels EM, Boesen M, Gudbergsen H, Bliddal H, Kristensen LE. Weight Loss for Patients With Gout and Concomitant Obesity: A Proof-of-Concept Randomized Trial. Arthritis Rheumatol 2024; 76:806-812. [PMID: 38169151 DOI: 10.1002/art.42790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Despite scarce evidence, guidelines recommend weight loss as a management strategy for patients with gout. We investigated the effect of an intensive dietary intervention on body weight and clinical measures of gout severity in individuals with obesity and gout. METHODS We conducted a 16-week randomized nonmasked parallel-group trial in Denmark, randomly assigning (one-to-one) individuals with obesity and gout to a low-energy diet or a control diet. The primary outcome was change in body weight. Key secondary outcomes were changes in serum urate (SU) level and visual analog scale-assessed pain and fatigue. RESULTS Between December 1, 2018, and June 1, 2019, 61 participants were included in the intention-to-treat population and randomly assigned to the intensive diet group (n = 29) or control diet group (n = 32). Participants had a mean age of 60.3 (SD 9.9) years and mean body mass index of 35.6 (SD 5.0), and 59 (97%) were men. After 16 weeks, there was a significant difference in change in body weight between the diet and control groups (-15.4 vs -7.7 kg; difference -7.7 kg [95% confidence interval -10.7 to -4.7], P < 0.001). Despite results being potentially in favor of a low-energy diet, we could not confirm differences in SU level changes and fatigue between groups. No differences in pain and gout flares were observed between groups. No serious adverse events or deaths occurred during the trial. CONCLUSION An intensive dietary intervention was safe and effectively lowered body weight in people with obesity and gout, but the weight loss did not directly translate into effects on SU level, fatigue, and pain.
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Affiliation(s)
- Robin Christensen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark, and University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Kristian Zobbe
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sabrina M Nielsen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark, and University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Marius Henriksen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders F Overgaard
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lene Dreyer
- Aalborg University Hospital, Aalborg, Denmark, and University of Aalborg, Aalborg, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark, Steno Diabetes Center Copenhagen, and Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, School of Medicine, University of Alabama at Birmingham (UAB), and UAB School of Public Health, Birmingham, Alabama
| | - Michael Doherty
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Pascal Richette
- Department of Rheumatology, Hôpital Lariboisière APHP Paris Nord and Université de Paris, INSERM, UMR-S 1132, Paris, France
| | | | - Karen Ellegaard
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Else M Bartels
- The Parker Institute, and Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mikael Boesen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Gudbergsen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Henning Bliddal
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lars Erik Kristensen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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Terkeltaub R. Emerging Urate-Lowering Drugs and Pharmacologic Treatment Strategies for Gout: A Narrative Review. Drugs 2023; 83:1501-1521. [PMID: 37819612 DOI: 10.1007/s40265-023-01944-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/13/2023]
Abstract
Hyperuricemia with consequent monosodium urate crystal deposition leads to gout, characterized by painful, incapacitating inflammatory arthritis flares that are also associated with increased cardiovascular event and related mortality risk. This narrative review focuses on emerging pharmacologic urate-lowering treatment (ULT) and management strategies in gout. Undertreated, gout can progress to palpable tophi and joint damage. In oral ULT clinical trials, target serum urate of < 6.0 mg/dL can be achieved in ~ 80-90% of subjects, with flare burden reduction by 1-2 years. However, real-world ULT results are far less successful, due to both singular patient nonadherence and prescriber undertreatment, particularly in primary care, where most patients are managed. Multiple dose titrations commonly needed to optimize first-line allopurinol ULT monotherapy, and substantial potential toxicities and other limitations of approved, marketed oral monotherapy ULT drugs, promote hyperuricemia undertreatment. Common gout comorbidities with associated increased mortality (e.g., moderate-severe chronic kidney disease [CKD], type 2 diabetes, hypertension, atherosclerosis, heart failure) heighten ULT treatment complexity and emphasize unmet needs for better and more rapid clinically significant outcomes, including attenuated gout flare burden. The gout drug armamentarium will be expanded by integrating sodium-glucose cotransporter-2 (SGLT2) inhibitors with uricosuric and anti-inflammatory properties as well as clinically indicated antidiabetic, nephroprotective, and/or cardioprotective effects. The broad ULT developmental pipeline is loaded with multiple uricosurics that selectively target uric acid transporter 1 (URAT1). Evolving ULT approaches include administering selected gut anaerobic purine degrading bacteria (PDB), modulating intestinal urate transport, and employing liver-targeted xanthine oxidoreductase mRNA knockdown. Last, emerging measures to decrease the immunogenicity of systemically administered recombinant uricases should simplify treatment regimens and further improve outcomes in managing the most severe gout phenotypes.
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Affiliation(s)
- Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA, 92093, USA.
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Hammam N, Li J, Kay J, Izadi Z, Yazdany J, Schmajuk G. Monitoring and Achievement of Target Serum Urate Among Gout Patients Receiving Long-Term Urate-Lowering Therapy in the American College of Rheumatology RISE Registry. Arthritis Care Res (Hoboken) 2023; 75:1544-1552. [PMID: 36039961 PMCID: PMC9971337 DOI: 10.1002/acr.25009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/11/2022] [Accepted: 08/25/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The American College of Rheumatology's (ACR) 2020 guidelines for the management of gout recommend using a treat-to-target approach to lower serum urate (SU). Using the ACR's Rheumatology Informatics System for Effectiveness registry, we examined the use of a treat-to-target approach among gout patients receiving long-term urate-lowering therapy (ULT) and followed longitudinally by rheumatologists. METHODS Included patients had one or more diagnoses for gout in 2018-2019 and continuous use of ULT for ≥12 months. We assessed the proportions of patients with SU monitoring and, among those tested, who achieved SU <6.0 mg/dl during the measurement year. Multilevel logistic regression adjusting for sociodemographics, comorbidities, region, and health care utilization was used to determine factors associated with SU monitoring and achievement of target SU. RESULTS A total of 9,560 were included. The mean ± SD age was 67.2 ± 12.7 years, 73.5% of patients were male, and 32.3% were non-White. Fifty-six percent of patients had at least 1 SU recorded during the measurement year; among patients with at least 1 SU recorded, 74% achieved the SU target. In multivariate analyses, non-White patients were slightly less likely to be tested or achieve a target SU. CONCLUSION Among gout patients receiving long-term ULT followed longitudinally by rheumatologists, more than half had a documented SU, and among those tested, three-quarters achieved the recommended SU target. Routine monitoring of SU is a first step toward improving quality of care for patients with gout.
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Affiliation(s)
- Nevin Hammam
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jing Li
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Julia Kay
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Zara Izadi
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Philip R. Lee Institute for Health Policy Research, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Philip R. Lee Institute for Health Policy Research, Department of Medicine, University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
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Anti-Gouty Arthritis and Anti-Hyperuricemia Properties of Sanghuangporus vaninii and Inonotus hispidus in Rodent Models. Nutrients 2022; 14:nu14204421. [PMID: 36297105 PMCID: PMC9608739 DOI: 10.3390/nu14204421] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022] Open
Abstract
Acute inflammation and hyperuricemia are associated with gouty arthritis. As an edible and therapeutic mushroom, Sanghuangporus vaninii (SV) has an inhibitory effect on tumorigenesis, and Inonotus hispidus (IH) exhibits anti-tumor, anti-inflammatory, and antioxidant properties. In this study, uric acid (UA) and xanthine oxidase (XOD) levels in hyperuricemic mice were examined to determine the regulatory effects of SV and IH. SV and IH reversed the pathogenic state of elevated UA levels in the serum and reduced levels of XOD in the serum and liver of mice with hyperuricemia. SV and IH affected the inflammatory response in rats with acute gouty arthritis. Compared to vehicle-treated rats, monosodium urate crystals (MSU) increased the swelling ratio of the right ankle joints. SV and IH administration significantly reduced swelling and inflammatory cell infiltration. SV reduced the levels of interleukin-8 (IL-8) and chemokine ligand-2 (CCL-2), whereas IH reduced the levels of matrix metalloproteinase-9 (MMP-9), CCL-2, and tumor necrosis factor-α (TNF-α), which were confirmed in articular soft tissues by immunohistochemistry. In summary, our data provide experimental evidence for the applicability of SV and IH in gouty arthritis and hyperuricemia treatment.
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Schlesinger N, Brunetti L, Androulakis I. Does seasonality of the microbiota contribute to the seasonality of acute gout flare? Clin Exp Rheumatol 2022; 40:1793-1800. [PMID: 35383564 PMCID: PMC9869072 DOI: 10.55563/clinexprheumatol/hdtge7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/09/2022] [Indexed: 01/26/2023]
Abstract
Gout, the most common inflammatory arthritis worldwide, is an auto-inflammatory metabolic disease that leads to monosodium urate crystal deposition. Hyperuricaemia is a significant risk factor for the development of gout; however, hyperuricaemia alone is not sufficient to induce gout.Gout flares have circadian rhythms. Gout flares vary during the day and have strong seasonality, with flares being more common in the spring. The reasons for the predominance of flares in the spring are unclear since serum urate (SU) levels show seasonal variation; however, SU levels are highest in the summer.Immune function varies significantly throughout the year, with enhanced immune responses increasing during the winter. In addition, chronic disruption of circadian rhythms is associated with metabolic syndrome and diseases driven by metabolism. The most telling example relates to Xanthine oxidase (XOD/XDH). The analysis of XOD/XDH established its circadian regulation and demonstrated that inhibition of the activity of XOD is characterised by distinct, crossregulating diurnal/seasonal patterns of activity.The gastrointestinal microbiota of gout patients is highly distinct from healthy individuals. In a small series of gout patients, Bacteroides caccae and Bacteroides xylanisolvens were found to be enriched. Bacteroidales levels were highest during the spring and summer, and loading values were highest in the spring.Our review discusses gout's circadian rhythm and seasonality, possible influences of the microbiome on gout due to our new knowledge that Bacteroidales levels were highest during spring when gout is most common, and potential opportunities for treatment based on our current understanding of this interaction.
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Affiliation(s)
- N. Schlesinger
- Division of Rheumatology and Gout Center, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - L. Brunetti
- Ernest Mario School of Pharmacy, Piscataway, NJ
| | - I.P. Androulakis
- Biomedical Engineering Department, Rutgers University, New Brunswick, NJ, USA
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Abstract
PURPOSE OF REVIEW The global burden of gout is rising, as are the prevalence of associated comorbidities, all-cause mortality and societal costs. In this review, we discuss recent advances in epidemiology and treatment strategies for gout. RECENT FINDINGS Genetic factors and obesity are prominent contributors to hyperuricemia and gout, while dietary factors contribute to less variance in serum urate, though can still have some contribution to population attributable risk. A consensus statement by the Gout, Hyperuricemia and Crystal-Associated Disease Network outlined appropriate terminology regarding gout, which will aid in communication about various aspects of the disease. The 2020 American College of Rheumatology gout guideline offers comprehensive evidence-based recommendations for the management of hyperuricemia using urate-lowering therapy, prophylaxis when initiating urate-lowering therapy, treatment of gout flare and adjunctive management strategies. There is improved understanding of risk factors for allopurinol hypersensitivity syndrome and well tolerated use of allopurinol in chronic kidney disease. Trial data have provided new insights regarding cardiovascular risk with febuxostat. Several new drug therapies are being tested for both urate-lowering efficacy and gout flare management. SUMMARY Although there have been significant advances in understanding of risk factors and treatment approaches, gout remains suboptimally managed. There is substantial need for improving gout management efforts and gout education among patients and clinicians.
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Abstract
PURPOSE OF REVIEW Although gout is a common, well-recognized, and extensively researched rheumatologic disease, it continues to be underappreciated and undertreated. Although the prevalence of gout has been rising over the past several decades, adherence to urate lowering therapy continues to be suboptimal. Recent studies have underscored the potential success of guideline-directed therapy. RECENT FINDINGS Adherence to gout treatment continues to be suboptimal according to multinational metaanalyses. Moreover, studies measuring adherence are prone to overestimation and each methodologic approach has intrinsic limitations. Adherence may be analyzed from the perspective of patient adherence to taking a medication, or provider adherence to treatment guidelines. In addition to considering traditional risk factors, adherence should be viewed through the lens of healthcare disparities. The RAmP-Up trial and Nottingham Gout Treatment trial demonstrate the success of protocolized gout treatment using existing guidelines for reference. SUMMARY Standardized gout treatment protocols should be established for all primary care and specialty practices. Two successful methods of improving adherence include using nonphysician providers to coordinate urate lowering therapy titration and monitoring serum urate. Having more frequent outpatient visits to focus on direct patient care and education has also been successful.
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Pascual E, Andres M, Sivera F. Gout. J Clin Rheumatol 2020; 26:208-212. [DOI: 10.1097/rhu.0000000000001492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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