be safely used for a prolonged period of time:
intensified urate-lowering therapy with XOI plus
uricosuric, that is, rapidly debulking ULT. Lifelong
XOI monotherapy might be adequate to keep the
patient out of the danger zone for gout attacks after
an intensified XOI + uricosuric time period.
Case study 4
A 62-year-old man having renal transplantation
30 years prior, myocardial infarction 25 years
prior; calciphylaxis cutis one year prior with
Staphylococcal bacteraemia from leg ulcers due
to calciphylaxis and portal hypertension with
hypersplenism without liver cirrhosis. During his
hospital stay, he developed a fulminant left-sided
arthritis of PIP5 left sided and MTP1 bilaterally. He
remembered having a similar attack annually over
the last four years only during hospital stays
Physical examination A man recovering from
a pneumosepsis with oligoarthritis and redness over
affected joints with weight 74kg and BMI 20 with
redness over MTP1 on both sides and PIP 5 on the
left side.
Ultrasonography Double contour sign a the
MTP1 cartilage bilaterally and many intraarticular
reflections in his left-sided PIP 5.
Puncture of MTP1 Tophous debris at polarisation
microscopy
X-rays forefeet Not done.
Gout calculator 13 (highly suggestive for gout)
Laboratory test Serum urate 710 micromolar
(12.10mg/dl) with serum creatinine 227 and
CRP 200; haemoglobin 6.2mM and platelets 116;
fractional urate excretion was not measured as total
renal function was clearly a major problem.
Course Dietary advice and started allopurinol 50mg
daily aiming for a redefined target: any lowering
of serum urate plus trying to get a setting without
ongoing attacks
In the most severe cases, renal function is
diminished to a very low level (<20ml/min) with
still significant tophaceous disease or bulky disease.
The primary goal is then redefined as getting the
patient free of attacks with a glucocorticoid and/or
colchicine regimen, or, if not tolerated, interleukin-1
blockade such as with canakinumab or off-label
anakinra. Simulateneously, any urate-lowering
strategy with dietary restrictions regarding purines
and ULT with allopurinol or febuxostat can be
12 | 2018 | hospitalpharmacyeurope.com
References
1 Roddy E, Doherty M.
Epidemiology of gout. Arthritis
Res Ther 2010;12:223.
2 Zhu Y, Pandya BJ, Choi HK.
Comorbidities of gout and
hyperuricemia in the US general
population: NHANES 2007–2008.
Am J Med 2012;125:679–87.
3 Richette P et al. Revisiting
comorbidities in gout: a cluster
analysis. Ann Rheum Dis
2015;74:142–7.
4 Jansen TL, Janssen M. The
American College of Physicians
and the 2017 guideline for the
management of acute and
recurrent gout: treat to avoiding
symptoms versus treat to
target. Clin Rheumatol
2017;36:2399–402.
5 Richette P et al. 2016 updated
EULAR evidence-based
recommendations for the
management of gout. Ann Rheum
Dis 2017;76(1):29–42.
6 Jansen TL. Rational
pharmacotherapy (RPT) in
goutology: define the serum uric
acid target & treat-to-target
patient cohort and review on
urate lowering therapy (ULT)
applying synthetic drugs. Joint
Bone Spine 2015;82(4):225–9.
undertaken. If renal function still exceeds the 20ml/
min level, adding a uricosuric should be considered.
In some instances, a uricolytic uricase therapy can
be offered, particularly if a bridging debulking
therapy of XOI + uricosuric is considered ineffective.
A three-month debulking period of uricase can be
quite effective if conservative XOI and/or uricosuric
can be continued afterwards. Without alternative
long-term options, short-term uricase is of no
use unless monthly uricase can be offered for
chronic maintenance therapy. The predominant
problem with PEGylated uricase for long-term use
is antibody formation, resulting in loss of efficacy
or anaphylaxis, and the slightly increased mortality
associated with these potent serum urate reductions.
Case study 5
A healthy 38-year-old female without a family
history of gout and suffering from a similar attack
in MTP1 two years prior reported an MTP1 arthritis
in the ninth week of her second pregnancy. Healthy
lifestyle but no specific diet. She had polycystic
ovary syndrome, hypertension, and obesity.
Physical examination A healthy young female
with weight 100kg and BMI 30.8 with redness over
the right MTP1
Ultrasonography Double contour sign rightsided
MTP1 with grade 2-3 power Doppler;
X-rays forefeet: not possible because of pregnancy.
Gout calculator score 11 (highly suggestive for
gout).
Laboratory test Serum urate 550 micromolar
(9.25mg/dl) with GFR >60 serum creatinine 90; urate
excretion 4.3mM (72.28mg/dl) ; fractional urate
excretion 4.3%
Course To ascertain the gout diagnosis, a puncture
was carried out and many monosodium urate
needles were present in the aspirate; initially
dietary advice (reduce purine ingestion and increase
coffee intake) with low dose prednisone 10mg daily
for 3–5 days if needed. This resulted in a significant
improvement during her pregnancy, but afterwards,
serum urate was unchanged and allopurinol
treatment was started.
Conclusions
The patient journey in gout clearly shows that
patients might be looking for medical attention
for chronic arthropathy or severe acute attacks
on one hand, or for a structural solution of the
hyperuricaemia-induced sequelae on the other.
Patients often only present to specialised care at
an advanced stage, and then only a few treatment
options remain; the earlier GPs are involved in the
patient journey, the more options for individualised
pharmacotherapeutic regimens exist. 5 Clinicians
might be helped by realising the patient journey and
the different phenotypes of gout patients: with high
purine/calorie intakes and normal versus subnormal
urate excretion. In finding personalised effective
treatment, one should start with dietary advice and
the possibility of lifelong treatment assessed; 5 some
patient phenotypes are clearly more into lifelong
treatment than others. If urate excretion is low
but effective, predefined targets cannot be reached
easily and if renal excretion still is adequate, then
uricosurics in addition with uptitrated XOIs may
be considered as any serum urate target is often
within reach. 5,6 The more pharmaceutical options
available, the more phenotyping is warranted to
optimise an individual’s journey. However, once
safe and very potent urate-lowering regimens are
available, these might become the new panacea for
any gout patient.