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Premachandra KH, Day RO, Roberts DM. Managing hyperuricemia and gout in chronic kidney disease: a clinical conundrum. Curr Opin Nephrol Hypertens 2021; 30:245-251. [PMID: 33399392 DOI: 10.1097/mnh.0000000000000691] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD. RECENT FINDINGS There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD. SUMMARY ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits.
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Affiliation(s)
- Kulanka H Premachandra
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
- St Vincent's Clinical School, University of New South Wales
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
- St Vincent's Clinical School, University of New South Wales
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
- St Vincent's Clinical School, University of New South Wales
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Better outcomes for patients with gout. Inflammopharmacology 2020; 28:1395-1400. [PMID: 32095979 DOI: 10.1007/s10787-020-00694-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/11/2020] [Indexed: 12/27/2022]
Abstract
Gout is increasing in prevalence despite effective pharmacotherapies. Barriers to effective management are largely educational deficiencies. Sufferers, usually men, need to understand more about gout, especially that maintaining serum urate below 0.36 mmol/L will eliminate recurrent attacks. Also, of great importance is appreciating that sub-optimal adherence to urate-lowering therapy (ULT) will result in a return of attacks. Prescribers also need to understand that acute attacks are likely to occur in the first few months of urate-lowering therapy (ULT), but these can be mitigated by commencing with a dose of ULT reflective of renal function and escalating the dose slowly, every 2-5 weeks until target serum urate is achieved. Prophylaxis against acute attacks over the initial 6 months period of ULT can be enhanced further with concomitant colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs).Gout is largely managed in primary care. Rates of adherence to ULT are 50% or less, worse than most other chronic illnesses. Efforts at educating primary care physicians to, firstly, manage gout effectively and, secondly, to educate their gout patients sufficiently have not been successful. Allied health practitioners, such as nurses, working with prescribers in primary care settings and given the mandate to educate and manage patients with gout, have been spectacularly effective. However, this approach is resource intensive. 'Personalised' eHealth interventions show promise as an alternative strategy, notably in improving adherence to ULT.Numerous applications for smart phones (apps) are now available to assist people with chronic health conditions. Their design needs to accommodate the barriers and enablers perceived by patients to maintaining adherence to prescribed therapies. Personalised feedback of serum urate may represent an important enabler of adherence to ULT in the case of gout.Harnessing mobile apps to support patients managing their chronic illnesses represents an important opportunity to enhance health outcomes. Rigorous, patient-centred and driven development is critical. These tools also require careful evaluation for effectiveness.
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Day RO, Lau W, Stocker SL, Aung E, Coleshill MJ, Schulz M, Bechara J, Carland JE, Graham GG, Williams KM, McLachlan AJ. Management of gout in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Richard O. Day
- St Vincent's Hospital Clinical School; UNSW Medicine; Sydney Australia
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
| | - Wendy Lau
- Westmead Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Sophie L. Stocker
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Eindra Aung
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
| | - Mathew J. Coleshill
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Marcel Schulz
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Jacob Bechara
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Jane E. Carland
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | | | | | - Andrew J. McLachlan
- Sydney Pharmacy School; University of Sydney; Sydney Australia
- Department of Clinical Pharmacology; St Vincent's Hospital; Sydney Darlinghurst Australia
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Day RO, Kannangara DR, Stocker SL, Carland JE, Williams KM, Graham GG. Allopurinol: insights from studies of dose–response relationships. Expert Opin Drug Metab Toxicol 2016; 13:449-462. [DOI: 10.1080/17425255.2017.1269745] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Richard O. Day
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Sydney, Australia
- St Vincent’s Clinical School, UNSW Australia, Darlinghurst, Sydney, Australia
| | - Diluk R.W. Kannangara
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Sydney, Australia
- St Vincent’s Clinical School, UNSW Australia, Darlinghurst, Sydney, Australia
| | - Sophie L. Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Sydney, Australia
- School of Medical Sciences, UNSW Australia, Kensington, Sydney, Australia
| | - Jane E. Carland
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Sydney, Australia
- School of Medical Sciences, UNSW Australia, Kensington, Sydney, Australia
| | - Kenneth M. Williams
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Sydney, Australia
- School of Medical Sciences, UNSW Australia, Kensington, Sydney, Australia
| | - Garry G. Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Sydney, Australia
- School of Medical Sciences, UNSW Australia, Kensington, Sydney, Australia
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Zhao J, Huang Y. Salivary uric acid as a noninvasive biomarker for monitoring the efficacy of urate-lowering therapy in a patient with chronic gouty arthropathy. Clin Chim Acta 2015; 450:115-20. [PMID: 26276048 DOI: 10.1016/j.cca.2015.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/07/2015] [Accepted: 08/09/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Monitoring blood uric acid (UA) is important in all patients on urate-lowering therapy so that the selection of the effective drugs and dosage adjustments could be made until the target level is reached. The issue is that frequent needle jabs are unacceptable. Reported mean levels of salivary UA were 185-240 μmol/l in healthy adults. A linear correlation was demonstrated between UA concentrations in saliva and plasma. We monitored salivary UA instead of plasmatic UA in a patient with gout. METHODS Allopurinol and benzbromarone were used as the therapeutic drugs. Salivary UA; urinary UA and creatinine; and plasmatic UA, creatinine, kynurenine and tryptophan were measured by HPLC. RESULTS Salivary UA indicated the efficacy of therapy accurately and conveniently. After eight weeks therapy, the weekly mean levels of salivary UA were reduced and maintained to <300 μmol/l, which was equivalent to <360 μmol/l of plasmatic UA according to the salivary UA/plasmatic UA ratio of this patient. CONCLUSION Measurement of salivary UA is a noninvasive and useful way for monitoring the status of hyperuricemia and the therapeutic efficacy of urate-lowering therapy. It has value for the management of hyperuricemia and gout.
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Affiliation(s)
- Jianxing Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine and Shanghai Institute of Hypertension, Shanghai, China.
| | - Ying Huang
- Department of Pathophysiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Singh JA, Reddy SG, Kundukulam J. Risk factors for gout and prevention: a systematic review of the literature. Curr Opin Rheumatol 2011; 23:192-202. [PMID: 21285714 PMCID: PMC4104583 DOI: 10.1097/bor.0b013e3283438e13] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Our objective was to perform a systematic review of risk factors and prevention of gout. We searched Medline for fully published reports in English using keywords including but not limited to 'gout', 'epidemiology', 'primary prevention', 'secondary prevention', 'risk factors'. Data from relevant articles meeting inclusion criteria were extracted using standardized forms. RECENT FINDINGS Of the 751 titles and abstracts, 53 studies met the criteria and were included in the review. Several risk factors were studied. Alcohol consumption increased the risk of incident gout, especially beer and hard liquor. Several dietary factors increased the risk of incident gout, including meat intake, seafood intake, sugar sweetened soft drinks, and consumption of foods high in fructose. Diary intake, folate intake, and coffee consumption were each associated with a lower risk of incident gout and in some cases a lower rate of gout flares. Thiazide and loop diuretics were associated with higher risk of incident gout and higher rate of gout flares. Hypertension, renal insufficiency, hypertriglyceridemia, hypercholesterolemia, hyperuricemia, diabetes, obesity, and early menopause were each associated with a higher risk of incident gout and/or gout flares. SUMMARY Several dietary risk factors for incident gout and gout flares are modifiable. Prevention and optimal management of comorbidities are likely to decreased risk of gout. Research in preventive strategies for the treatment of gout is needed.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, Alabama, USA.
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Abstract
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.
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Affiliation(s)
- T K Hoskison
- Department of Internal Medicine, The University of Oklahoma College of Medicine-Tulsa, 4502 East 41st Street, Tulsa, OK 74135, USA
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Raut AA, Sunder S, Sarkar S, Pandita NS, Vaidya ADB. Preliminary study on crystal dissolution activity of Rotula aquatica, Commiphora wightii and Boerhaavia diffusa extracts. Fitoterapia 2008; 79:544-7. [PMID: 18644427 DOI: 10.1016/j.fitote.2008.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Accepted: 06/03/2008] [Indexed: 11/15/2022]
Abstract
Several Ayurvedic plants are known to have activity against diverse urinary crystals. The traditional knowledge of Ayurveda, collective clinical experience in arthritis and the earlier experimental studies on urinary crystals led to the selection of three plants, viz. Rotula aquatica, Commiphora wightii Bhandari syn. C.mukul. and Boerhaavia diffusa for screening anticrystal activity against basic calcium phosphate (BCP), calcium pyrophosphate (CPPD) and monosodium urate monohydrate (MSUM). The effects of each plant were assayed on microcrystals in 24-well microplates in vitro. Our results show that the aqueous extracts of only R. aquatica and C. wightii have shown crystal dissolving activity against MSUM.
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Affiliation(s)
- Ashwinikumar A Raut
- Bharatiya Vidya Bhavan's Swami Prakashananda Ayurveda Research Centre, 13th North-South Road, Juhu, Mumbai-400 049, India.
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Becker MA, Schumacher HR, Wortmann RL, MacDonald PA, Eustace D, Palo WA, Streit J, Joseph-Ridge N. Febuxostat compared with allopurinol in patients with hyperuricemia and gout. N Engl J Med 2005; 353:2450-61. [PMID: 16339094 DOI: 10.1056/nejmoa050373] [Citation(s) in RCA: 814] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Michael A Becker
- University of Chicago Pritzker School of Medicine, Chicago, USA.
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López Jiménez M, García Puig J. Gota úrica. Med Clin (Barc) 2004; 123:138-42. [PMID: 15274808 DOI: 10.1016/s0025-7753(04)74438-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Gout is an inflammatory response to deposition of monosodium urate crystals in and around joints. It is primarily a disease of adult men. In acute gout, treatment options include non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids, administered either intra-articularly, orally or parenterally. Asymptomatic hyperuricaemia does not require specific treatment, but should prompt screening for atherosclerosis risk factors, and general lifestyle modification to reduce serum urate levels. Gout presents differently in the elderly. Both women and men are affected, attacks are frequently polyarticular and in the upper limbs, and the gout may be associated with diuretic use, hypertension and renal impairment. In patients with peptic ulcer disease, selective COX-2 inhibitors provide another treatment option. In the presence of renal impairment, allopurinol is the treatment of choice for urate lowering therapy, but doses of allopurinol and colchicine must be adjusted. Urate lowering therapy should only be used if recurrent episodes of gout occur despite aggressive attempts to reverse or control the underlying causes. It should not be introduced or discontinued during an acute episode of gout, and gout prophylaxis (NSAIDs or colchicine) should be prescribed during the introduction of urate lowering therapy.
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Affiliation(s)
- S van Doornum
- Department of Rheumatology, Alfred Hospital, Melbourne, VIC
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Yamanaka H, Togashi R, Hakoda M, Terai C, Kashiwazaki S, Dan T, Kamatani N. Optimal range of serum urate concentrations to minimize risk of gouty attacks during anti-hyperuricemic treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1998; 431:13-8. [PMID: 9598023 DOI: 10.1007/978-1-4615-5381-6_3] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To find an optimal range of urate concentrations wherein the risk of attacks during the initial 6 months of treatment is minimized, data from 350 gouty patients treated with anti-hyperuricemic drugs were retrospectively analyzed. We determined the optimal range of urate concentrations to be 4.6-6.6 mg/dl. If urate concentrations were within this range, the risk ratio of an attack as opposed to outside of the range was 0.705 (95% confidence interval, 0.629-0.791). The increase (or decrease) in urate concentration in one month associated with minimal risk of gouty attacks was also determined. The lowest risk ratio of attack (0.451) occurred at a range of -0.1 to 0.6 mg/dl/month increase in urate concentrations (95% confidence interval, 0.310-0.655). In conclusion, we propose that urate concentrations during the initial 6 months of anti-hyperuricemic therapy should be maintained within a range of 4.6-6.6 mg/dl, and reduction in the urate concentrations during treatment should be as slow as possible.
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Affiliation(s)
- H Yamanaka
- Institute of Rheumatology, Tokyo Women's Medical College, Japan
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Parkes AJ, Coper LC. Inappropriate use of medications in the veteran community: how much do doctors and pharmacists contribute? Aust N Z J Public Health 1997; 21:469-76. [PMID: 9343890 DOI: 10.1111/j.1467-842x.1997.tb01737.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
There is widespread inappropriate use of pharmaceuticals. Problems are with the prescribing and dispensing as well as with the taking of medicines. Levels of potentially inappropriate prescribing were estimated in the population of Australian veterans and war widows. This group tends to have multiple medical conditions and therefore to rely on medication therapy. These factors, and the average age of the population (72 years), increase the possibility of drug misadventures in this group. Despite the obvious hazards, a large number of high-risk prescribing situations were detected. Although some of the problems can be reduced through changes in prescribing behaviour, the solution does not lie in the hands of doctors alone.
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Affiliation(s)
- A J Parkes
- Department of Veterans' Affairs, Canberra, ACT
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Abstract
We now have sufficient knowledge to be able to identify the factors contributing to hyperuricemia in most patients with gout. Some of these factors, such as obesity, a high-purine diet, regular alcohol consumption, and diuretic therapy, may be correctable. In patients with persistent hyperuricemia, regular medication should lower the serum urate concentration to an optimal level. The continuing challenge is to educate patients about correctable factors and the importance of regular medication and ensure their compliance so that attacks of gout do not recur.
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Affiliation(s)
- B T Emmerson
- University of Queensland, Department of Medicine, Princess Alexandra Hospital, Woolloongabba, Brisbane, Australia
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Kelmann V. Preventing acute gout when starting allopurinol therapy. Colchicine or NSAIDS? Med J Aust 1993. [DOI: 10.5694/j.1326-5377.1993.tb141376.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Parkes AJ, Coper LC. Inappropriate use of medications in the veteran community: how much do doctors and pharmacists contribute? Aust N Z J Public Health 1977. [DOI: 10.1111/j.1467-842x.1977.tb01096.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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