Gout in the elderly. Clinical presentation and treatment

Considerations for Choosing First-Line Urate-Lowering Treatment in Older Patients with Comorbid Conditions

Gout is the most common inflammatory arthritis in adults. The prevalence of gout increases with age. Urate-lowering treatment (ULT) among older patients is often challenging in that patients frequently suffer insufficient effectiveness or adverse events due to comorbidities, concurrent medications, and altered pharmacokinetics. The large-scale randomized controlled trials (RCTs) directly investigating gout patients regarding cardiovascular (CV) safety have only recently been introduced; CARES and FAST compared the CV safety of the two xanthine oxidase inhibitors (XOis), febuxostat versus allopurinol, in patients with gout. Based on the CARES trial that showed CV concerns with febuxostat, the current international guidelines recommend allopurinol as first-line ULT in gout, while preserving other agents as a second-line treatment, despite a higher potency of febuxostat. XOis would be more suitable than uricosurics to treat older patients with gout due to the high prevalence of chronic kidney disease (CKD) in older patients. However, allopurinol alone might not achieve the target serum uric acid levels below 6 mg/dL and CKD might confer an increased risk of allopurinol induced cutaneous adverse reactions in older patients. Furthermore, as well as the later analysis of CARES participants who were lost to follow-up, data from the FAST trial and real-world studies suggest non-inferior CV safety for febuxostat compared to allopurinol even in the presence of CV diseases. Thus, febuxostat use in older patients with renal impairment may be more positively considered. The combination therapy of a novel uricosuric, verinurad, plus febuxostat reduced albuminuria in hyperuricemic patients with type 2 diabetes and CKD in a phase 2a trial, and further RCTs are awaited. Finally, the sodium-glucose cotransporter-2 inhibitor class of oral hypoglycemic agents, known to exert beneficial CV and renal effects independent of glycemic control, have shown a uricosuric effect and could be used as adjunctive therapy in older patients with cardiorenal comorbidities.

Dosage individualization proposed for anti-gout medications among the patients with gout

BACKGROUND

The conventional one-size-fits-all approach has been criticized for almost all drugs used especially for chronic diseases, including gout. The present study was aimed to explore the need of individualization and optimization of the dose of anti-gout medications among gout patients.

METHODS

Cross-sectional study was carried out among 384 randomly selected new gout patients visiting two gout treatment centers at Lalitpur Metropolitan City, Nepal and who were taking antigout medications. Patients not taking anti-gout medications and not showing willingness to participate were excluded. The eGFR was calculated with the CKD Epidemiology Collaboration (CKD-EPI) creatinine equation (2009). Doses to be individualized were decided based on the Renal Drug Handbook and verified with the BNF 80. Data were analyzed via R 4.0.3 by applying the multinomial logistic regression to analyze statistical significance of risk with various predictors, and considering a p-value <0.05 statistically significant. Comorbidities were coded as per the ICD-11 coding and medicines were coded according to the WHO Guidelines for ATC classification and DDD assignment 2020.

RESULTS

The high risk of progression to CKD increased in the age range 54-63 and ≥84 years by 17.77 and 43.02 times, respectively. Also, high risk increased by 29.83 and 20.2 times for the overweight and the obese respectively. Aceclofenac 100mg was prescribed for maximum patients (30.5%). Need of dose individualization was realized in 30 patients, with maximum (7) in case of etoricoxib 90mg. Various glucocorticoids were prescribed for 36.9% patients, out of whom 3.8%required dose individualization and 15.9% patients with xanthine oxidase inhibitors, out of whom 1.3% required dose individualization.

CONCLUSION

Thirty cases required dose individualization, which was although minimal but could have meaningful impact on the clinical success of the individual patient. Based on the recommendation on dose individualization, those patients could be optimized on their therapy on future follow ups.

Allopurinol Loaded Transferosomes for the Alleviation of Symptomatic After-effects of Gout: An Account of Pharmaceutical Implications

Background:

The present study assessed the transdermal potential of transferosomes loaded with allopurinol for the treatment of gout.

Methods:

Transferosomes of allopurinol were composed of different ratios of tween-80, soya lecithin and solvent using a thin-film hydration method. Transferosomes were characterized for Scanning Electron Microscopy (SEM), zeta potential, % entrapment efficiency (%EE), Fourier Transform Infrared Spectroscopy (FTIR), in-vitro drug release and kinetics as well as stability. Then, optimized formulation was incorporated in gel and evaluated for viscosity, pH, extrudability, homogeneity, skin irritation study, spreadability, ex vivo skin permeation study, flux, and stability.

Results:

SEM studies suggested that vesicles were spherical and zeta potential were in the range of -11.4 mV to -29.6 mV and %EE was 52.4- 83.87%. FTIR study revealed that there was no interaction between allopurinol and excipients during the preparation of transferosomes. The cumulative percentage of drug release from various transferosomes was ranged from 51.87 to 81.87%. A transferosomal gel of F8 formulation was prepared using dispersion method reported pseudoplastic rheological behavior, optimum pH, spreadability and maximum drug permeation i.e. 79.84% with flux 13.06 g/cm2/hr, followed zero-order release kinetics. Irritation and in-vivo studies of optimized transferosomal gel G8 on rabbits revealed better results than the standard allopurinol.

Conclusion:

This research suggested that allopurinol loaded transferosomal gel can be potentially used as a transdermal drug delivery system for the treatment of gout.

Long-term opioid use among patients with chronic gout: a cross-sectional study of a sample cohort in South Korea

OBJECTIVES

This study aimed to determine trends in the prevalence of chronic opioid users among patients with chronic gout in South Korea from 2002 to 2015 and to investigate the factors associated with chronic opioid use among patients with chronic gout.

METHODS

We performed a population-based cohort study and extracted data from the National Health Insurance Service database in South Korea. We included all adult patients (age ≥ 18 years) with a diagnostic code of M1A* (chronic gout) according to the International Classification of Disease (10th revision).

RESULTS

The prevalence of chronic opioid users among patients with chronic gout has gradually increased from 4.0% in 2002 to 19.4% in 2015. After excluding the patients who had a history of cancer or other rheumatic diseases, a total of 18,042 patients with chronic gout were included in this cross-sectional cohort study in 2015, of which 993 (5.5%) were long-term opioid users. In a multivariable model, older age, female sex, Charlson Comorbidity Index > 2, long-term use of other analgesics, such as pregabalin, gabapentin, paracetamol, and glucocorticoids, and the use of other gout medication (colchicine) were independently associated with higher rates of long-term opioid use among patients with chronic gout.

CONCLUSION

Chronic opioid users among patients with chronic gout increased from 2002 to 2015 in South Korea. Female sex, older age, comorbid status, and the use of other non-opioid analgesics were independently associated with higher rates of long-term opioid use among patients with chronic gout. Key Points • Chronic opioid users among patients with chronic gout have increased from 2002 to 2015 in South Korea. • Among patients with chronic gout, 5.5% were long-term opioid users. • Female sex, older age, comorbid status, and the use of other non-opioid analgesics were associated with higher rates of long-term opioid use.

Do etoricoxib and indometacin have similar effects and safety for gouty arthritis? A meta-analysis of randomized controlled trials

Background

Gout, a common medical condition that causes pain, can be treated by painkillers and anti-inflammatories. Indometacin and etoricoxib are two such drugs. However, no synthesized evidence exists comparing etoricoxib with indometacin in treating patients with gout.

Methods

We searched PubMed, Embase, Ovid MEDLINE, Web of Science, ScienceDirect, and the Cochrane Library without restrictions on language or publication date for potential randomized clinical trials comparing etoricoxib with indometacin for gout. The meta-analysis was conducted using a random-effects model.

Results

Search results yielded 313 references from six electronic databases, four of which met the eligibility criteria. These four were randomized clinical trials, and they involved a total of 609 patients with gouty arthritis. No significant differences were observed in pain score change, tenderness, or swelling between etoricoxib and indometacin; the mean differences were −0.05 (95% CI, −0.21 to 0.10), −0.06 (95% CI, −0.18 to 0.05), and −0.04 (95% CI, −0.17 to 0.09). However, the pooled data revealed that significantly fewer overall adverse events occurred in the etoricoxib group (n=105, 33.5%) than in the indometacin group (n=130, 44.1%) and the risk ratio was 0.77 (95% CI, 0.62–0.94).

Conclusion

Our meta-analysis revealed that etoricoxib and indometacin have similar effects on pain relief. However, etoricoxib has a significantly lower risk of adverse events than does indometacin, especially digestive system-related adverse events.

Benefit-risk of corticosteroids in acute gout patients: An updated meta-analysis and economic evaluation

The efficacy, safety and health-economic outcomes were compared between corticosteroid and non-corticosteroid treatments in acute gout patients. All electronic literatures comparing the curative effects or full economic evaluations of corticosteroids versus non-corticosteroids on acute pain in acute gout patients and published until June 30, 2017 in any language were searched through PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. Pooled odds ratios with 95% confidence intervals and standard(or weighted) mean difference were calculated using random-or fixed-effects models according to the I² statistic test of heterogeneity. Economic elevations were combined through qualitative narrative synthesis. Finally, seven randomized controlled trials(RCTs) involving 929 patients were included here and suggested corticosteroids had comparable analgesic efficacy to non-corticosteroids on day 5. As for inflammation and PGA, corticosteroids might outperform non-corticosteroids in reducing tenderness and swelling. Corticosteroids versus non-corticosteroids could significantly reduce incidence of only serious adverse advents, but not total adverse advents, with substantial heterogeneity. Qualitative narrative synthesis of economic elevation involving only one study shows corticosteroids are more cost-effective than indomethacin. The existing RCTs do not provide sufficient or precise evidence that corticosteroids are superior to non-corticosteroids in pain relief of acute gout patients. Therefore, studies on chronic use of corticosteroids or comparative studies with colchicine, tramadol and/or opiates may be needed in the future, as is patient satisfaction with analgesic control.

Efficacy and safety of etoricoxib compared with NSAIDs in acute gout: a systematic review and a meta-analysis

The aim is to study the efficacy and safety of etoricoxib in the treatment of acute gout, as compared with non-steroidal anti-inflammatory drugs (NSAIDs). We conducted a computerized search of electronic databases: PubMed, EMBASE, Web of Science, China Biology Medicine disc, and Cochrane Library. The search terms were as follows: gout arthritis, tophus, etoricoxib, indometacin naproxen, diclofenac, and NSAIDs. Articles were searched from 1983 until August 2014. A manual search of peer-reviewed English documents was performed by cross-checking the bibliographies of selected studies. These trials reported pain relief as the primary outcome. Tenderness, swelling, patients' global assessments of response to treatment, and investigators' global assessments of response to treatment were reported as the secondary outcomes. All adverse events were recorded for safety assessment. Six trials including 851 patients were identified. Both etoricoxib and NSAIDs had an effect on inflammation and analgesia. Compared with indometacin and diclofenac, etoricoxib had a lower incidence of adverse events. Etoricoxib 120 mg administered orally once daily has the same efficacy on acute gout as indometacin and diclofenac. Etoricoxib is tolerated better by patients than NSAIDs such as indometacin and diclofenac.

Identification of antihyperuricemic peptides in the proteolytic digest of shark cartilage water extract using in vivo activity-guided fractionation

A peptide that exerts antihyperuricemic activity after oral administration was identified from a microbial protease (alcalase) digest of the water extract of shark cartilage by in vivo activity-guided fractionation, using oxonate-induced hyperuricemic rats. Water extract of shark cartilage was first fractionated by preparative ampholine-free isoelectric focusing, followed by preparative reversed-phase liquid chromatography. The antihyperuricemic activity of the alcalse digests of the obtained fractions was evaluated using an animal model. Alcalase digests of the basic and hydrophobic fractions exerted antihyperuricemic activity. A total of 18 peptides were identified in the alcalase digest of the final active fraction. These peptides were chemically synthesized and evaluated for antihyperuricemic activity. Tyr-Leu-Asp-Asn-Tyr and Ser-Pro-Pro-Tyr-Trp-Pro-Tyr lowered the serum uric acid level via intravenous injection at 5 mg/kg of body weight. Furthermore, orally administered Tyr-Leu-Asp-Asn-Tyr showed antihyperuricemic activity. Therefore, these peptides are at least partially responsible for the antihyperuricemic activity of the alcalase digest of shark cartilage.

Advanced imaging in gout

OBJECTIVE

The purpose of this article is to describe the role of advanced imaging using ultrasound, CT, and MRI in the assessment and diagnosis of gout.

CONCLUSION

Dual-energy CT can quantitatively identify monosodium urate crystal deposits with high sensitivity and specificity within joints, tendons, and periarticular soft tissues. There are several characteristic ultrasound imaging findings, which include visualization of echogenic monosodium urate crystal deposition, tophus, and adjacent erosions. MRI is sensitive in showing soft-tissue and osseous abnormalities of gout, although the imaging findings are not specific. Gout commonly involves specific joints and anatomic structures, and knowledge of these sites and imaging appearances are clues to the correct diagnosis.

How to manage patients with gout

OBJECTIVES

Recently, after almost 50 years of dormancy, new therapeutic agents for the management of gout have entered the market or are in clinical development. In this article, the current guidelines for the diagnosis and management of gout are reviewed.

METHODS

Key papers for inclusion were identified by a PubMed search, and articles were selected according to their relevance for the topic, according to the authors' judgment.

RESULTS AND CONCLUSIONS

Although our therapeutic arsenal is strong, and effective gout management with urate lowering therapy improves many patient-reported outcomes in clinical trials, major gaps exist in patient understanding of disease and adherence to long-term therapy. Research is required to identify the optimal models of care for patients with gout. However, quality of care in gout can be enhanced through better gout-centered education. To properly manage gout, education of the gout patient is critical, since only the patient who understands their gout will stay with their medication long-term.

Role of apoptosis in mediating diclofenac-induced teratogenesis

Diclofenac (DCF) is among the most commonly used nonsteroidal anti-inflammatory drugs worldwide for the treatment of various conditions in postpubertal women. However, very limited information is available regarding its safety during pregnancy and teratogenecity. The present study was designed to elucidate the effects of DCF on the developing rat embryos during the major organogenesis period and investigate the critical role of apoptosis in bringing about these congenital anomalies. Embryos were exposed in vitro to various concentrations of DCF, that is, 0, 3.75, 7.5 and 15 µg/ml for 24 h, respectively, and examined for the growth and differentiation at the end of the culture period for the presence of any specific malformations. Growth and developmental parameters such as weight of embryos, crown–rump length and number of somites were found to be lower in the embryos exposed to high concentrations of DCF (7.5 and 15.0 μg/ml) when compared with the untreated control. However, no significant difference in growth parameters was found between embryos exposed to 3.75 µg/ml and the control group. In parallel to this, flow cytometric analysis and DNA quantitation of cultured rat embryos were performed to verify the involvement of apoptosis in mediating DCF-induced teratogenesis. A concentration-dependent increase in apoptosis in embryos suggests a possible engagement of apoptosis in the role of DCF as a teratogenic agent. A detailed analysis of the actual effect of DCF on cellular apoptotic machinery necessitates further evaluation.

Safety of urate-lowering therapies: managing the risks to gain the benefits

Gout is a metabolic disorder of purine metabolism and uric acid elimination. Over time, acute gout can develop into a chronic, disabling arthropathy, often associated with multiple comorbidities. Gout patients have often been undertreated, partly because of the clinician's perceived risks of a therapy outweighing its potential benefits. The approval of new therapies to treat hyperuricemia in gout has led to a new understanding of gout management and medication safety regarding new and old therapies. This review focuses on potential safety issues of currently available urate-lowering therapies and outlines strategies to minimize risks so their benefits can be reached.

Comorbidities of gout and hyperuricemia in the US general population: NHANES 2007-2008

PURPOSE

The objective of this study was to estimate the latest prevalence of major comorbidities associated with gout and hyperuricemia in the US based on a recent, nationally representative sample of US men and women.

METHODS

Using data from 5707 participants aged 20 years and older in the National Health and Nutrition Examination Survey 2007-2008, we calculated the national prevalence and population estimates of major comorbidities according to gout status and various hyperuricemia levels, compared with those without these conditions. Case definitions of gout and comorbidities were based on an affirmative answer to a question that asked whether a physician or a health professional had diagnosed the corresponding condition.

RESULTS

Among these individuals with gout, 74% (6.1 million) had hypertension, 71% (5.5 million) had chronic kidney disease stage ≥2, 53% (4.3 million) were obese, 26% (2.1 million) had diabetes, 24% (2.0 million) had nephrolithiasis, 14% (1.2 million) had myocardial infarction, 11% (0.9 million) had heart failure, and 10% (0.9 million) had suffered a stroke. These proportions were substantially higher than those among individuals without gout (all P-values <.67). With increasing levels of hyperuricemia, there were graded increases in the prevalences of these comorbidities. In the top category (serum urate ≥10 mg/dL), 86% of subjects had chronic kidney disease stage ≥2, 66% had hypertension, 65% were obese, 33% had heart failure, 33% had diabetes, 23% had myocardial infarction, and 12% had stroke. These prevalences were 3-33 times higher than those in the lowest serum urate category (<4 mg/dL). Sex-specific odds ratios tended to be larger among women than men, and the overall comorbidity prevalence was highest among individuals with both gout and hyperuricemia.

CONCLUSIONS

These findings from the latest nationally representative data highlight remarkable prevalences and population estimates of comorbidities of gout and hyperuricemia in the US. Appropriate preventive and management measures of these comorbidities should be implemented in gout management, with a preference to strategies that can improve gout and comorbidities together.

Allopurinol to Febuxostat: How far have we come?

For decades allopurinol has been used as a xanthine oxidase inhibitor for treatment of hyperuricemia and gout. Although effective in many patients, some experience sensitivity to the drug. In some cases, this sensitivity may lead to allopurinol hypersensitivity disorder, which if untreated can be fatal. Recently the Food and Drug Administration has approved the use of febuxostat as an alternative therapy for hyperuricemia and gout. Febuxostat is a new xanthine oxidase inhibitor, but is not purine based and therefore decreases adverse reactions due to patient sensitivity. This review is a comprehensive look at the background of hyperuricemia and gout treatment with allopurinol compared to recent clinical studies with febuxostat. Each clinical study is evaluated and summarized, identifying the advances in treatment that have been made as well as the concerns that still exist with either treatment.

Unusual clinical presentations of gout

PURPOSE OF REVIEW

The dogmatic description of gout is described as an inflammatory crystal-induced arthropathy that afflicts peripheral joints. This manuscript describes many recent cases and unusual clinical presentations of gout. Emphasis is placed on the ability of gout to cause diagnostic dilemmas that can impact patient treatment and care.

RECENT FINDINGS

Various genetic mutations can predispose patients in developing early onset gout. Environmental exposures, medications, and certain patient populations can affect pathophysiology of uric acid, predisposing patients both typical and atypical manifestations of gout. Numerous reports have described gout deposition in unusual parts of the body, which can mimic unrelated disease processes.

SUMMARY

Although classic gout is still most commonly seen, the disease can manifest as with a wide array of presentations. It is likely that such atypical presentations are a result of a complexity of reasons. When presented with a diagnostic challenge in a patient with gout, the clinician should be aware of unusual manifestations of gout and consider it in the differential.

Management of hyperuricemia in gout: focus on febuxostat

Gout is the most common inflammatory arthritis in an elderly population, and can be diagnosed with absolute certainty by polarization microscopy. However, diagnosis may be challenging because atypical presentations are more common in the elderly. Management of hyperuricemia in the elderly with gout requires special consideration because of co-medication, contra-indications, and risk of adverse reactions. Urate-lowering agents include allopurinol and uricosuric agents. These also must be used sensibly in the elderly, especially when renal function impairment is present. However, if used at the lowest dose that maintains the serum urate level below 5.0 to 6.0 mg/dL (0.30 to 0.36 mmol/L), the excess urate in the body will eventually be eliminated, acute flares will no longer occur, and tophi will resolve. Febuxostat, a new xanthine oxidase inhibitor, is welcomed, as few alternatives for allopurinol are available. Its pharmacokinetics and pharmacodynamics are not significantly altered in patients with moderate renal function or hepatic impairment. Its antihyperuricemic efficacy at 80 to 120 mg/day is better than “standard dosage” allopurinol (300 mg/day). Long-term safety data and efficacy data on tophus diminishment and reduction of gout flares have recently become available. Febuxostat may provide an important option in patients unable to use allopurinol, or refractory to allopurinol.

Advances in the management of gout and hyperuricaemia

An acute attack of gouty arthritis is one of the most painful experiences reported throughout medical history. Therefore it is paramount to initiate appropriate therapy quickly in order to terminate the acute phase. This goal can be achieved with non-steroidal anti-inflammatory agents, colchicine, or corticosteroid-based therapies. Rarely, because of contraindications to these agents, only symptomatic treatment can be given until the attack subsides. The next step is to lower the serum urate level below the limit of solubility (i.e., below 40.8 mmol/L, or 6.8mg/dL) which reduces recurrences and begins to return the total body urate pool to normal. This equally important goal can be achieved by uricosuric agents or xanthine oxidase inhibitors, although the latter is generally favored. Allopurinol is the agent most commonly preferred because of its safety profile and ease of use, but there are known serious allergic reactions and untoward side effects that occasionally require discontinuation. Febuxostat, a xanthine oxidase inhibitor, and pegylated uricase are new agents under development and may be beneficial in these situations or when other comorbid conditions prevent the use of conventional treatments. Alcohol and dietary consumption are also related to hyperuricemia and acute gout. Recently beer, wine, and liquor were studied and the risk of gout varied according to the alcohol ingested. Furthermore, recent data sheds light on important dietary modifications that may help in the treatment of gout, and dispels certain beliefs about protein ingestion and the occurrence of acute gout. As we learn more about the associated conditions of hypertriglyceridemia, hypertension, and the metabolic syndrome, it may allow the tailoring of medical regimens that directly prevent or reduce recurrent attacks of gouty arthritis. There are specific approved treatments for these common comorbidities that have parallel effects of lowering serum urate levels. These recent findings may be especially important for treating refractory cases. While patient education remains a cornerstone to ensure compliance, other quality indicators for the management of this disease have been reported and should guide the clinician in the treatment of gout and result in improved care.

Impact of a rheumatology consultation service on the diagnostic accuracy and management of gout in hospitalized patients

OBJECTIVE

To determine if a hospital rheumatology consultation service improves diagnostic accuracy and adherence to treatment recommendations for gout.

METHODS

This was a retrospective, single-center, case-control study of consecutive hospitalized patients with gout. Demographic, diagnostic, and treatment variables were compared in patients with and without a rheumatology consultation (controls). American College of Rheumatology (ACR) preliminary criteria for the classification of acute gout and the European League Against Rheumatism (EULAR) recommendations were used to determine diagnostic accuracy. Adherence to EULAR drug management recommendations and Quality Indicators for treatment were compared between groups.

RESULTS

In total, 138 patients were studied. The mean (SD) age was 71.3 (13.4) years and 70% were men. Forty-eight (35%) patients had gout on admission, 90 (65%) during their hospital stay, and 8 (6%) had multiple attacks. A total of 79 (57%) patients had a rheumatology consultation. These patients had more joints involved (p < 0.001), more frequent synovial fluid analysis (p < 0.001), and fulfilled ACR classification criteria more frequently than those who did not have a rheumatology consultation (65% vs 37%; p = 0.002). Intraarticular corticosteroid use was more common (44% vs 12%; p < 0.001) in patients who were seen by rheumatology. In contrast, colchicine was used more frequently in controls (63% vs 40%; p = 0.006). Patients seen by rheumatology were more likely to use nonsteroidal antiinflammatory drugs or colchicine for gout prophylaxis while titrating allopurinol to target (p = 0.033).

CONCLUSION

A rheumatology consultation service for hospitalized patients with gout significantly improved the diagnostic accuracy and adherence to established guidelines for short and longterm treatment.

Urinary L-type fatty acid-binding protein can reflect renal tubulointerstitial injury

This study aimed to elucidate the role of L-type fatty acid-binding protein (L-FABP) in renal tubulointerstitial injury using a mouse adenine-induced renal injury model. C57BL/6 mice fed excess dietary adenine for 6 weeks showed a gradual increase in levels of blood urea nitrogen (BUN). They also showed severe tubulointerstitial pathological findings, such as fibrosis and macrophage infiltration without glomerular damage, which were attenuated by treatment with either allopurinol or Y-700, a new xanthine dehydroxygenase inhibitor. Because renal expression of L-FABP is defective in C57BL/6 mice, human L-FABP transgenic mice were fed an adenine-containing diet. Transgenic mice showed lower BUN levels and lower levels of pathological injury compared with wild-type mice. On the other hand, urinary levels and renal expression of L-FABP in the adenine group was significantly increased and attenuated by treatment with either allopurinol or Y-700. Urinary L-FABP was positively correlated with BUN levels and pathological damages in the tubulointerstitium. No increases in urinary protein, albumin, or N-acetyl-beta-D-glucosaminidase levels were found for 6 weeks in any group. In conclusion, we demonstrated that urinary L-FABP levels can be used to monitor both dynamics and drug responses in a mouse adenine-induced tubulointerstitial injury model.

Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial

BACKGROUND

Non-steroidal anti-inflammatory drugs and colchicine used to treat gout arthritis have gastrointestinal, renal, and cardiovascular adverse effects. Systemic corticosteroids might be a beneficial alternative. We investigated equivalence of naproxen and prednisolone in primary care.

METHODS

We did a randomised clinical trial to test equivalence of prednisolone and naproxen for the treatment of monoarticular gout. Primary-care patients with gout confirmed by presence of monosodium urate crystals were eligible. 120 patients were randomly assigned with computer-generated randomisation to receive either prednisolone (35 mg once a day; n=60) or naproxen (500 mg twice a day; n=60), for 5 days. Treatment was masked for both patients and physicians. The primary outcome was pain measured on a 100 mm visual analogue scale and the a priori margin for equivalence set at 10%. Analyses were done per protocol and by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN14648181.

FINDINGS

Data were incomplete for one patient in each treatment group, so per-protocol analyses included 59 patients in each group. After 90 h the reduction in the pain score was 44.7 mm and 46.0 mm for prednisolone and naproxen, respectively (difference 1.3 mm; 95% CI -9.8 to 7.1), suggesting equivalence. The difference in the size of change in pain was 1.57 mm (95% CI -8.65 to 11.78). Adverse effects were similar between groups, minor, and resolved by 3 week follow-up.

INTERPRETATION

Oral prednisolone and naproxen are equally effective in the initial treatment of gout arthritis over 4 days.

We can make gout management more successful now

PURPOSE OF REVIEW

The purpose of this editorial review is to identify and comment on factors contributing to the current less-than-optimal state of gout management and to emphasize immediate opportunities to improve management practices affecting many patients with gout.

RECENT FINDINGS

Numerous publications document deficits in the current management and clinical outcomes of gout despite detailed understanding of the pathogenesis and pathophysiology of the disorder, the ability to establish the diagnosis with certainty, and the likely effectiveness, for most patients, of available lifestyle and pharmacological interventions. Among impediments to successful gout management are diagnostic inaccuracy; a paucity of validated management recommendations to guide care providers; incomplete patient education about gout and the aims and modalities of management; suboptimal patient adherence, even to demonstrably effective therapeutic recommendations; comorbidities and drug interferences that complicate treatment of gout; patient groups at special risk for progression to chronic tophaceous gout; and limited urate-lowering alternatives.

SUMMARY

Recent publication of evidence-based recommendations for the diagnosis and management of gout and the impending availability of new urate-lowering agents suggest that this is an opportune time to initiate professional and patient education efforts toward improved management of this increasingly common disorder.

Systemic corticosteroids for acute gout

BACKGROUND

Gout is one of the most frequently occurring rheumatic diseases, worldwide. Given the well-known drawbacks of the regular treatments for acute gout (non-steroidal anti-inflammatory drugs (NSAIDs), colchicine), systemic corticosteroids might be safe alternatives.

OBJECTIVES

To assess the efficacy and safety of systemic corticosteroids in the treatment of acute gout in comparison with placebo, NSAIDs, colchicine, other active drugs, other therapies, or no therapy.

SEARCH STRATEGY

Searches were done in the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007); MEDLINE (1966 to 2007) through PubMed; EMBASE (1974 to 2007); Web of Science (1975 to 2007); LILACS (1986 to 2007); and databases of ongoing trials (up to April 2007).

SELECTION CRITERIA

Randomized controlled trials and controlled clinical trials investigating the use of systemic corticosteroids in the treatment of acute gout were included.

DATA COLLECTION AND ANALYSIS

Two review authors decided independently which trials to include. The same review authors also collected the data in a standardised form and assessed the methodological quality of the trial using validated criteria. When possible, continuous and dichotomous data were summarised statistically.

MAIN RESULTS

Three head to head trials involving 148 patients (74 systemic corticosteroids; 74 comparator drugs) were included. Placebo-controlled trials were not found. In the studies, different kinds of systemic corticosteroids and different kinds of control drugs were used, both administered in different routes. Intramuscular triamcinolone acetonide was compared respectively to oral indomethacine, and intramuscular adrenocorticotropic hormone (ACTH); oral prednisolone (together with a single intramuscular diclophenac injection) was compared to oral indomethacine (together with a single placebo injection). Outcome measurements varied: average number of days until total relief of signs, mean decrease of pain per unit of time in mm on a visual analogue scale (VAS) - during rest and activity. In the triamcinolone-indomethacine trial the clinical joint status was used as an additional outcome. Clinically relevant differences between the studied systemic corticosteroids and the comparator drugs were not found; important safety problems attributable to the used corticosteroids were not reported. The quality of the three studies was graded as very low to moderate. Statistical pooling of results was not possible.

AUTHORS' CONCLUSIONS

There is inconclusive evidence for the efficacy and effectiveness of systemic corticosteroids in the treatment of acute gout. Patients with gout did not report serious adverse effects from systemic corticosteroids, when used short term.

Gold salts, D-penicillamine and allopurinol

Gold salts have been used in the treatment of patients with rheumatoid arthritis since 1927 [1]. After a controlled study, the Empire Rheumatism Council [2], confirmed the effectiveness of gold salts for the treatment of rheumatoid arthritis. Even today, chrysotherapy has remained one of the major therapeutic modalities in the second line treatment of progressive rheumatoid arthritis. Gold salts are also used in the treatment of pemphigus vulgaris [3] and bronchial asthma [4]. Before the introduction of an orally administered gold compound, auranofin (triethylphosphine gold tetra-acetyl glycopyranoside), to clinical use [5-7], parenterally administered gold salts, such as sodium aurothiomalate and gold thioglucose comprised chrysotherapy. The frequency and severity of the side effects for patients treated with parenteral gold versus those given oral gold preparations are significantly different [8-10]. With introduction of newer parental DMARDs, toxicity has been reduced using combination therapy [10a, 10b].

Prevalence of the metabolic syndrome in individuals with hyperuricemia

PURPOSE

The link between hyperuricemia and insulin resistance has been noted, but the prevalence of the metabolic syndrome by recent definitions among individuals with hyperuricemia remains unclear. Our objective was to determine the prevalence of the metabolic syndrome according to serum uric acid levels in a nationally representative sample of US adults.

METHODS

By using data from 8669 participants aged 20 years and more in The Third National Health and Nutrition Examination Survey (1988-1994), we determined the prevalence of the metabolic syndrome at different serum uric acid levels. We used both the revised and original National Cholesterol Education Program Adult Treatment Panel (NCEP/ATP) III criteria to define the metabolic syndrome.

RESULTS

The prevalences of the metabolic syndrome according to the revised NCEP/ATP III criteria were 18.9% (95% confidence interval [CI], 16.8-21.0) for uric acid levels less than 6 mg/dL, 36.0% (95% CI, 32.5-39.6) for uric acid levels from 6 to 6.9 mg/dL, 40.8% (95% CI, 35.3-46.4) for uric acid levels from 7 to 7.9 mg/dL, 59.7% (95% CI, 53.0-66.4) for uric acid levels from 8 to 8.9 mg/dL, 62.0% (95% CI, 53.0-66.4) for uric acid levels from 9 to 9.9 mg/dL, and 70.7% for uric acid levels of 10 mg/dL or greater. The increasing trends persisted in subgroups stratified by sex, age group, alcohol intake, body mass index, hypertension, and diabetes. For example, among individuals with normal body mass index (<25 kg/m2), the prevalence increased from 5.9% (95% CI, 4.8-7.0), for a uric acid level of less than 6 mg/dL, to 59.0%, (95% CI, 20.1-97.9) for a uric acid level of 10 mg/dL or greater. With the original NCEP/ATP criteria, the corresponding prevalences were slightly lower.

CONCLUSIONS

These findings from a nationally representative sample of US adults indicate that the prevalence of the metabolic syndrome increases substantially with increasing levels of serum uric acid. Physicians should recognize the metabolic syndrome as a frequent comorbidity of hyperuricemia and treat it to prevent serious complications.

Prevalence of the metabolic syndrome in patients with gout: the Third National Health and Nutrition Examination Survey

OBJECTIVE

To determine the prevalence of metabolic syndrome among patients with gout and to examine the association between the 2 conditions in a nationally representative sample of US adults.

METHODS

Using data from 8,807 participants age >or=20 years in the Third National Health and Nutrition Examination Survey (1988-1994), we determined the prevalence of metabolic syndrome among individuals with gout and quantified the magnitude of association between the 2 conditions. We used both the revised and original National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III) criteria to define metabolic syndrome.

RESULTS

The prevalence (95% confidence interval [95% CI]) of metabolic syndrome according to revised NCEP/ATP III criteria was 62.8% (51.9-73.6) among individuals with gout and 25.4% (23.5-27.3) among individuals without gout. Using 2002 census data, approximately 3.5 million US adults with a history of gout have metabolic syndrome. The unadjusted and age- and sex-adjusted odds ratios (95% CI) of metabolic syndrome for individuals with gout were 4.96 (3.17-7.75) and 3.05 (2.01-4.61), respectively. With the original NCEP/ATP criteria, the corresponding prevalences were slightly lower, whereas the corresponding odds ratios were slightly higher. The stratified prevalences of metabolic syndrome by major associated factors of gout (i.e., body mass index, hypertension, and diabetes) remained substantially and significantly higher among those with gout than those without gout (all P values <0.05).

CONCLUSION

These findings indicate that the prevalence of metabolic syndrome is remarkably high among individuals with gout. Given the serious complications associated with metabolic syndrome, this frequent comorbidity should be recognized and taken into account in long-term treatment and overall health of individuals with gout.

Crystal-Associated Arthritis in the Elderly

Since the original recognition of these conditions in 1961, a great deal has been learned about the pathogenesis, clinical manifestations, and appropriate treatment of gout and pseudogout, and the role of crystals in osteoarthritis has been further defined. The variable manifestations of crystal-induced arthritis in elderly populations has led to a greater need for proper diagnosis and treatment strategies for these increasingly common forms of arthritis.

Metabolic diseases: gout

Gout is a disease of antiquity but is increasing once again in prevalence despite availability of reasonably effective treatments. This may be related to a combination of factors, including diet, obesity, and diuretic use. Allergic reactions, noncompliance, drug interactions, and sometimes inefficacy all limit the effective use of current hypouricemic agents. There are new treatments for gout on the horizon, including febuxostat, a nonpurine inhibitor of xanthine oxidase with a potentially better combination of efficacy and side effects than allopurinol. Diagnostic progress is being made in that ultrasound may offer a noninvasive means of diagnosing tophaceous deposits in and around joints. The increasing prevalence of gout means that dermatologists will see more cutaneous manifestations of gout, including tophi, draining sinus tracts, panniculitis, and dystrophic calcifications.

Atraumatic Joint and Limb Pain in the Elderly

Patients who visit the emergency department often have complaints of joint and limb pain. The differential diagnosis, clinical presentation, and treatment choices can be vastly different in the young- or middle-aged population compared with the elderly population, and the concerns of each group must be addressed. The emergency physician is in a unique position in that they are frequently the first to see these individuals and have the opportunity to intervene before permanent disability ensues. Some of the more common etiologies of atraumatic joint and limb pain, including crystal deposition diseases such as gout and pseudogout, osteoarthritis, septic arthritis, and inflammatory arthritides such as rheumatoid arthritis will be addressed in this article. In addition,several arthritides specific to the elderly population such as poly-myalgia rheumatica and associated giant cell arteritis will be covered. Finally a discussion of cervical and lumbar disc disease, as well as gait disorders, and their impact on the elderly, will be presented.

Pathophysiology, Clinical Presentation and Treatment of Gout

Gout is a common form of inflammatory arthritis that has been managed primarily in general medical practices for centuries. It appears that there has been an increasing prevalence of gout over the past decades, implying a growing public health burden. Accurate diagnosis and recognition of the various stages and manifestations of gout enable realistic goal setting for management. Recent evidence suggests new risk factors and potentially refutes others. Management of gout requires characterising and modifying risk factors and associated disorders, and commonly initiating drug therapy. Pharmacotherapy of gout includes the management of acute flares with anti-inflammatory agents such as NSAIDs and glucocorticoids and long-term treatment with urate-lowering drugs. Although pharmacotherapy is generally safe and effective, there are caveats and limitations to all gout therapies. Patient non-adherence and errors with the use of drugs for gout treatment are important factors leading to medical failures. With early intervention, careful monitoring and patient education, gout is a condition that can be managed very effectively. The advent of new drugs (such as febuxostat and urate oxidase [uricase]) and enhanced understanding of the pathogenesis of gout continue to improve our therapeutic options, particularly in a subset of patients with refractory disease and those who are intolerant to currently available medications.

Febuxostat compared with allopurinol in patients with hyperuricemia and gout

BACKGROUND

Febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase, is a potential alternative to allopurinol for patients with hyperuricemia and gout.

METHODS

We randomly assigned 762 patients with gout and with serum urate concentrations of at least 8.0 mg per deciliter (480 micromol per liter) to receive either febuxostat (80 mg or 120 mg) or allopurinol (300 mg) once daily for 52 weeks; 760 received the study drug. Prophylaxis against gout flares with naproxen or colchicine was provided during weeks 1 through 8. The primary end point was a serum urate concentration of less than 6.0 mg per deciliter (360 micromol per liter) at the last three monthly measurements. The secondary end points included reduction in the incidence of gout flares and in tophus area.

RESULTS

The primary end point was reached in 53 percent of patients receiving 80 mg of febuxostat, 62 percent of those receiving 120 mg of febuxostat, and 21 percent of those receiving allopurinol (P<0.001 for the comparison of each febuxostat group with the allopurinol group). Although the incidence of gout flares diminished with continued treatment, the overall incidence during weeks 9 through 52 was similar in all groups: 64 percent of patients receiving 80 mg of febuxostat, 70 percent of those receiving 120 mg of febuxostat, and 64 percent of those receiving allopurinol (P=0.99 for 80 mg of febuxostat vs. allopurinol; P=0.23 for 120 mg of febuxostat vs. allopurinol). The median reduction in tophus area was 83 percent in patients receiving 80 mg of febuxostat and 66 percent in those receiving 120 mg of febuxostat, as compared with 50 percent in those receiving allopurinol (P=0.08 for 80 mg of febuxostat vs. allopurinol; P=0.16 for 120 mg of febuxostat vs. allopurinol). More patients in the high-dose febuxostat group than in the allopurinol group (P=0.003) or the low-dose febuxostat group discontinued the study. Four of the 507 patients in the two febuxostat groups (0.8 percent) and none of the 253 patients in the allopurinol group died; all deaths were from causes that the investigators (while still blinded to treatment) judged to be unrelated to the study drugs (P=0.31 for the comparison between the combined febuxostat groups and the allopurinol group).

CONCLUSIONS

Febuxostat, at a daily dose of 80 mg or 120 mg, was more effective than allopurinol at the commonly used fixed daily dose of 300 mg in lowering serum urate. Similar reductions in gout flares and tophus area occurred in all treatment groups.

Recent advances in the epidemiology of gout

Gout remains among the most common of all inflammatory arthridities with an incidence that appears to have risen. Evidence is accumulating to support lifestyle and dietary factors, such as heavy consumption of beer and liquor as well as diets rich in meats and seafood as important gout risk factors. There is also a renewed interest in important associations between gout and other comorbidities like hypertension and cardiovascular disease. The importance of hyperuricemia on health considerations beyond the musculoskeletal system is an area worthy of even more study.

Crystal-Associated Arthritis in the Elderly

Since the original descriptions of the involvement of crystals in arthritis, our understanding of the clinical syndromes of gout and pseudogout, and the role of basic calcium crystals in arthritis has increased. Gout is usually considered an affliction confined to middle-aged men, but has an increasing prevalence in older populations, with unique and often atypical features. Calcium pyrophosphate dihydrate crystal deposition disease is common in elderly patients. The diagnosis of both of these common forms of arthritis and the need to individualize therapy in patients with other medical problems remain important clinical challenges to the practicing physician.

Prevalence of Comorbid Conditions and Prescription Medication Use Among Patients With Gout and Hyperuricemia in a Managed Care Setting

BACKGROUND

: Comorbid disorders and multiple prescription drug use are common among patients with gout and/or hyperuricemia and may influence the clinical course and outcome of gout.

OBJECTIVE

: We wanted to document the conditions and associated medications in a large group of patients with gout in a managed care setting.

METHODS

: This study was a 2-year, retrospective, administrative claims analysis examining comorbid conditions and medication use among managed care enrollees with gout/hyperuricemia across the United States.

RESULTS

: Of the 9482 study subjects (82.1% men, mean age 52 years), 57.9% had hypertension, 45.3% had a lipid disorder, 32.5% had both conditions, and 19.9% had diabetes mellitus. During the 24-month follow-up period, subjects had 5 +/- 3.14 (mean +/- standard deviation) different comorbid conditions and filled prescriptions for of 11.0 +/- 7.90 different medications. The most commonly filled prescriptions included antihypertensive drugs, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins), and nonsteroidal antiinflammatory drugs (NSAIDs).

CONCLUSIONS

: The study indicates a high prevalence of both comorbid conditions and multiple medication use among managed care enrollees with gout and/or hyperuricemia. Heightened awareness of these associated disorders is important because they may warrant treatment of their own accord and often some modification of gout management. Drugs, particularly diuretics and prophylactic aspirin, could potentially contribute to the development of hyperuricemia and gout.

Gout: a clinical and radiologic review

Gout is a group of diseases characterized by arthritis and results from a disturbance of urate metabolism with the deposition of monosodium urate crystals in the joints and soft tissues. Often, but not invariably, the serum urate levels are elevated as a result of overproduction or underexcretion of uric acid. Clinical manifestations include acute and chronic arthritis, tophaceous deposits, interstitial renal disease, and uric acid nephrolithiasis. The diagnosis is based on the identification of uric acid crystals in joints, tissues, or body fluids. Acute episodes are treated with colchicine, NSAIDs, or steroids. Long-term management includes treatment with uricosuric agents or xanthine oxidase inhibitors.

Efficacy and safety profile of treatment with etoricoxib 120 mg once daily compared with indomethacin 50 mg three times daily in acute gout: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy and safety of etoricoxib and indomethacin in the treatment of patients with acute gout.

METHODS

A randomized, double-blind, active-comparator study was conducted at 42 sites. A total of 189 men and women (> or =18 years of age) who were experiencing an acute attack (< or =48 hours) of clinically diagnosed gout were treated for 8 days with etoricoxib, 120 mg/day (n = 103), or indomethacin, 50 mg 3 times a day (n = 86). The primary efficacy end point was the patient's assessment of pain in the study joint (0-4-point Likert scale) over days 2-5. Safety was assessed by adverse experiences (AEs) occurring during the trial.

RESULTS

Etoricoxib demonstrated clinical efficacy comparable to that of indomethacin in terms of the patient's assessment of pain in the study joint. The difference in the mean change from baseline over days 2-5 was -0.08 (95% confidence interval -0.29, 0.13) (P = 0.46), which fell within the prespecified comparability bounds of -0.5 to 0.5. Secondary end points over the 8-day study, including the onset of efficacy, reduction in signs of inflammation, and patient's and investigator's global assessments of response to therapy, confirmed the comparable efficacy of the two treatments. The etoricoxib-treated patients had a numerically lower incidence of AEs (43.7%) than did the indomethacin-treated patients (57.0%) and a significantly lower incidence of drug-related AEs (16.5% versus 37.2%; P < 0.05).

CONCLUSION

Etoricoxib at a dosage of 120 mg once daily was confirmed to be an effective treatment for acute gout. Etoricoxib was comparable in efficacy to indomethacin at a dosage of 50 mg 3 times daily, and it was generally safe and well tolerated.

A literature review of the epidemiology and treatment of acute gout

BACKGROUND

Gout is the most common cause of inflammatory arthritis in men aged >40 years and is frequently encountered in clinical practice.

OBJECTIVE

The goal of this article was to review the published literature on the epidemiology, treatment, and estimated burden of illness of acute gout.

METHODS

Articles on gout published in English between 1980 and June 2002 were identified through a MEDLINE search. Relevant clinical studies and review articles were found using the text- and keyword-search term gout alone and in combination with epidemiology, prevalence, incidence, complications, outcome, quality of life, economics, cost, prevention or drug therapy. The reference lists of identified articles, especially review articles, were checked for any additional studies that might have been missed in the original MEDLINE search.

RESULTS

The epidemiology of gout in various geographic regions has been well documented. Data suggest that environmental, racial, and hereditary factors may influence the development of gout, and that the prevalence of gout appears to be on the rise worldwide. Evidence from well-designed clinical studies evaluating drug therapies for gout is limited. Therapies for acute gout include corticotropin, corticosteroids, colchicine or, more often, nonsteroidal anti-inflammatory drugs (NSAIDs), which have shown comparable efficacy. A recent study suggests that etoricoxib, a new cyclooxygenase-2-selective inhibitor, may be as effective as and better tolerated than traditional NSAIDs in the treatment of gout. Urate-lowering therapy, prophylactic colchicine, and low-dose NSAIDs are used for the long-term prophylaxis of gout. However, all acute and prophylactic therapies are associated with adverse events. Using an economic model for gout, the annual direct burden of illness for new cases of acute gout can be estimated at 27,378,494 US dollars in the United States.

CONCLUSIONS

Gout is an increasingly prevalent condition worldwide and creates a heavy economic burden. Available treatments are generally effective; however, they are not devoid of adverse events. Well-designed, long-term, controlled clinical trials evaluating the comparative efficacy and tolerability of treatments for gout are needed.