Gout

Abstract

Comorbidities are common in gout and impact both on the development of gout and management decisions. The metabolic syndrome (including hypertension, cardiovascular disease, chronic kidney disease, type II diabetes, obesity and hyperlipidaemia) in particular has a close association. Assessment and management of gout should include screening and appropriate management of these comorbidities. Conversely patients with the metabolic syndrome should be screened for gout. A treat-to-target approach aiming for sustained serum urate <0.36 mmol/L (<0.30 mmol/L in those with tophi) underpins successful gout management. Treatment needs to be individually tailored and is influenced by specific comorbidities. Historically, patients with chronic kidney disease have been under-treated with allopurinol, the most commonly used hypouricaemic agent, due to toxicity concerns. Recent evidence suggests a start low, go slow approach is safe and effective. Febuxostat, a recently introduced xanthine oxidase inhibitor, is a welcome therapeutic addition, particularly in those intolerant or refractory to allopurinol, and appears effective in patients with chronic kidney disease. General measures including avoidance of medications which increase uric acid and nutritional advice are relevant to all gout patients, especially those with the metabolic syndrome. The relationship between hyperuricaemia, gout and cardiovascular disease, insulin resistance and type 2 diabetes is complex; nonetheless treatment principles for gout are unchanged with potential benefits for these comorbidities. Solid organ transplant recipients are an emerging group of patients developing gout; whilst management principles are unchanged, special care is required regarding drug interactions. Evidence for treating asymptomatic hyperuricaemia to improve cardiovascular outcomes remains unsubstantiated and is not currently recommended. NSAIDS, colchicine and corticosteroids remain the agents of choice for treatment of acute gout; NSAIDs are usually contraindicated in the setting of chronic kidney disease and cardiovascular disease. Colchicine is an alternative but needs to be used cautiously due to its narrow therapeutic index and interaction with several cardiac medications; nonetheless it has re-emerged as a useful agent particularly in low dose. Oral prednisone or intra-articular corticosteroids are the preferred option if NSAIDs and colchicine are ineffective or contraindicated. In summary, patients with gout typically have several comorbidities, and it is increasingly recognised that the optimal management of gout relies not only on achieving a target urate but on screening and instituting appropriate treatment of any associated comorbidities.