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BEYOND THE FLARE

IMPLEMENTING SOLUTIONS FOR

HYPERURICEMIA GOAL ACHIEVEMENT IN

THE PRIMARY CARE PRACTICE

Paul Doghramji, MD FAAFPCollegeville Family PracticeCollegeville, PA

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APPROXIMATELY HOW MANY GOUT PATIENTS (IN STUDIES) ACHIEVE URIC ACID GOAL OF <6.0 MG/DL?1.90%

2.80%

3.70%

4.60%

5.Less than half

6.Unsure

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APPROXIMATELY HOW MANY PATIENTS IN YOUR PRACTICE ACHIEVE THE GOUT URIC ACID GOAL OF <6.0 MG/DL?

1.90%

2.80%

3.70%

4.60%

5.Less than half

6.Unsure

URATE LOWERING THERAPY (ULT) USUALLY EXTEND OVER WHAT PERIOD OF TIME?

1.3 months

2.6 months

3.1 year

4.Remainder of life

5.Unsure

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WHAT IS CONSIDERED TREATMENT “SUCCESS” FOR A GOUT PATIENT?

1. Relief of flare pain

2. Reduction in flares

3. Reduction in uric acid

4. Reduction in uric acid to <6.0mg/mL or <5.0mg/mL

5. 1 & 2

6. 1, 2 & 3

7. 1, 2 & 4

8. 2 & 4

9. Unsure

1. A beer binge

2. Ingestion of large quantities of seafood

3. Reduced kidney function

4. Hyperuricemia

5. A sore toe

6. All of the above

7. Unsure

THE PRECIPITATING FACTOR IN A FIRST ACUTE EPISODE OF GOUT IS USUALLY: (CHOOSE BEST ANSWER)

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GETTING PATIENTS TO GOAL IS DIFFICULT. IF A PATIENT DOES NOT ACHIEVE GOAL, FURTHER CONSIDERATION SHOULD BE GIVEN TO: (SELECT THE BEST CHOICE)

1. Complete reduction of alcohol

2. Weight loss

3. Bland diet

4. Stronger anti-inflammatories

5. Increased exercise

6. Combination therapies

7. Unsure

WHAT TOP PRACTICE CHANGEWOULD YOU CONSIDER

OVER THE NEXT 3 MONTHS?

1. Place gout on the practice ”radar” by incorporating a “treat-to-target” approach reinforced by practice enhancements and training

2. Utilize pharmacologic combinations to increase numbers of patients reaching goal

3. ‘Set’ and ‘Implement’ sUA goals- education and discussion with both patients and the practice TEAM

4. Consider adding or switching medication when sUA goals are not achieved

5. Follow-up patients through office monitoring every 6 months to assess adherence and goal achievement

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EDU

CA

TIO

NA

L O

BJEC

TIV

ES 1. Incorporate a “treat-to-target” approach and practice system for achieving SUA goals in practice

2.Expand the therapeutic armamentaria to reach target SUA by

including new and emerging dual action/combination

approaches

3. Educate office staff and patients regarding gout beyond pain

relief, and provide focus on UA goals

4.Establish a practical gout management workflow that

includes the patient, signals for therapeutic ‘adherence,’ and

practice systems for long-term monitoring and management.

GOUT AND THE PROVIDER• Most cases of gout are treated in the primary care setting1

• Recent audit shows that fewer than half of patients achieved target sUA over 12 mos.2

• Another survey found opportunities for gout management and treatment3

• Education regarding achievement of gout goals

• Implement office monitoring

• SUA (serum uric acid): every 6 months

• Screening for comorbidities

• ULT considerations and proper monitoring

1. Becker MA, Schumacher HR, Romain PL Treatment of Acute Gout; 2016 UpToDate; UpToDate.com2. Roddy E, Packham J, Obrenovic K, Ledingham JM. Rheumatology 2018 doi:10.1093/rheumatology/kex521.3. Zychowicz M, Howson A, Kim D. et al. Improving gout management in primary care. 2016 AAFNP National Conference Poster.

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GOUT RISK FACTORS

• Advancing age

• Male gender

• Family history of gout

• Obesity

• Certain drugs: diuretics, low

dose aspirin, cyclosporin

• Alcohol, especially beer

and binge drinking

• High fructose diet

• Organ transplants

• Thyroid problems

• Myeloproliferative disorders

Singh JA, Reddy SG, Kundukulam J. Risk Factors for Gout and Prevention 2011 Curr Opin Rheum 23(2):192-202.

COMORBIDITIES IN GOUT• Individuals in the US general population with gout and hyperuricemia have

significantly higher comorbidities1

ComorbiditiesGout-Hyperuricemia

No Gout-No Hyperuricemia

Hypertension 77.7 24.3

Obesity 55.6 27.0

Diabetes 26.9 6.7

Nephrolithiasis 20.2 7.8

Myocardial infarction 11.6 2.5

Heart Failure 11.7 1.4

Stroke 11.8 2.3

Renal Impairment 8.8 1.8

1 Zhu Y, et al. Am J Med. 2012 Jul;125:679-687.e1.

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CKD ASSOCIATED WITH GOUT

•71% of US patients with gout have stage 2 or

higher CKD1

•Annual reduction in GFR

•Healthy adults

• 0.8-1.3 mL/min

•Untreated hyperuricemic adults

• 2.5 mL/min/1.73 m2

1 Martillo M, Karis E, Crittenden dB, Pillinger MH Gout Co-Morbidities: Prev. and Mgmt. 2013 Future Med. 212-225.

CLINICAL GUIDELINES UNDERUTILIZED IN GOUT

•Only 52.8% of PCPs provide optimal medication therapy

for acute gout attacks

•<20% of PCPs recommended optimal Tx for tophaceous

gout

•<20% of PCPs use ULT with dose titration and prophylaxis

Harrold LR, et al. Rheumatology. 2013;6:1623-29.Edwards NL. Curr Rheumatol Rep. 2011;13:154-159.

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A C

OU

PLE

OF

NO

TES •Most common inflammatory arthritis in adults in the

Western world1

•Characterized by hyperuricemia and effects of acute and chronic inflammation in joints and bursa

•Caused an an inflammatory response to MSU re hyperuricemia2

•Agonizing and chronically painful

•New hope for patients with new drug discoveries- things arechanging!!

1. Zhu Y et al. Arthritis Rheum 2011;63:3136-3141.2. Martinon F, et al. Nature 2006:440;237-241.

WHERE DOES URATE COME FROM?

•About two-thirds of uric acid is generated

endogenously by the body, while one-third comes

from purines in the diet1 No Uricase in Humans and Higher Primates

1 Fam AG. J Rheum. 2002;29:1350-1355; 2 Hediger MA, et al. Physiology. 2005;20:125-133; 3 Johnson RJ, et al. J Comp Physiol B. 2009;179:67-76; 4 Terkeltaub RA. In: Primer on the Rheumatic Diseases. 12th ed. Atlanta, GA: Arthritis Foundation; 2001:305-324.

Purine Catabolism2-4

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THE CRYSTALS AND THE PAIN

• Purine catabolism= uric acid

formation

• 98% of UA forms

monosodium salts

• MSU crystals for in synovial

fluid when solubility limits

are exceeded

• Crystals cause an

inflammatory reaction

THE TREAT 2 TARGET ‘DILEMMA’•>sUA = Increased flares

•T2T sUA = may cause increased

flares initially

•Suboptimal treatment of sUA can

lead to more flares every year

• In the long haul, T2T is

recommended for reduction of flares

and prevention of joint destructionSingh JA, Uhlig T. Chasing crystals out of the body: will treat to serum urate target for gout help us get there?2017 Ann Rheum Dis 76(4);629-31.

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GOUT AND THE PATIENT

•Significant morbidity

•Work-related disability

•Loss of productivity

•Increase healthcare costs

•All-cause hospital admissions

Rimler E, Lom J, Higdon, Cosco D, Jones D. A Primary Care Perspective on Gout 2016 Open Urol & Neph Journ: 9, (Suppl 1:M5)27-34.

ACR: THERAPY AND PREVENTION OF ACUTE FLARES

•Gouty arthritis attack (acute flare)•Reduce pain, inflammation, and disability quickly

•Treat with pharmacologic therapy within 24 hours of onset

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TREATMENT FOR ACUTE GOUTY INFLAMMATION

•First-line options1-3

•NSAIDs*•Oral Colchicine•Glucocorticosteroids*

•Intra-articular •Parenteral*

•Combinations if severe or refractory

1 Terkeltaub RA. N Eng J Med. 2003;349:1647-1655.2 Terkeltaub R. Nat Rev Rheumatol. 2010;6:30-38.3 Terkeltaub RA, et al. Arthritis Rheum. 2010;62:1060-1068.

NOW FOR sUA- TREAT TO TARGET-WHAT DOES IT MEAN??

•T2T Recommendations1,2,3

•sUA lowered and maintained at

<6 mg/dL in all patients with

gout (<5 mg/dL in those with

tophi or frequent attacks)

•sUA should be measured

‘regularly’ for dose adjustments

if needed1. Richette P, Doherty M, Pascual et al. 2016 EULAR Updates Mgmt of Gout Ann Rheum Dis 76:29-42.2. Zhang et al. EULAR Evidence-based recommendations for Gout P II 2006 Ann Rheum Dis 65:1312-24.3. Khanna D, Fitzgerald JD, Khanna PP et al. 2012 ACR guidelines for mgmt. of gout 2012 ArthCare Res 64:1431-46.

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WHY DO URIC ACID GOALS MATTER

• HRQOL is impaired compared to age-

and sex-matched study controls1

• Reduce pain and disability2

• Prevent/limit joint destruction3

• Strong association between gout and

metabolic syndrome4

• Independent risk factor for CV disease

and mortality5

1.Chandratre P, Mallen C, Richardson J, et al. HRQOL of life in primary care 2018 Sem in Arth Rheum 2. Osterhaus JT, et al. Patient reported outcomes associated with gout. 2005 Arth Rheum 52(9 Suppl):S401-2.3. DAlbeth N, Doyle AJ Imaging tools to measure treatment response in gout. 2018 Rheum 57(suppl_1):i27-i34.4. McCracken E, Monaghan M, Sreenivasan S. Patho. Of the metabolic syndrome. 2018 Clin Derm 36(1):14-20.5. Stack AG, Hanley A, Casserly LF et al. QIM 2013; 106:647-58.

HOW DO YOU ACHIEVE GOAL, OR T2T?1. Know gout- and place it on the practice radar (TEAM)

2. Know that treating an acute attack is NEVER enough

3. Know that getting SUA < 6mg/dL (< 5mg/dL with tophi)

is THE TARGET, and follow up tests every 6 months or

more

4. Know how to use pharmacologics- both traditional and

new,emerging- for optimal results

5. Know that >25% of patients will need ‘combinations of

meds’ to achieve goal

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PHARMACOLOGIC URATE-LOWERING OPTIONS AND STRATEGIES

•Xanthine Oxidase Inhibitors (XOI)

ALLOPURINOL- PURINE-LIKE

•Available in US

since 1966

•Purine-like

backbone,

converted in liver

to oxypurinol

O

Hypoxanthine

NN

NN

O

O

Xanthine

N

N

N

N

Uric acid

N

N

N

O

N

O

O

O

Allopurinol

NN

NN

Oxypurinol

NN

NN

O

O

Normal half-life 24 hoursRenal Elimination

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ALLOPURINOL(ZYLOPRIM, ALOPRIM, LOPURIN)

•Starting dosage of allopurinol should be no greater

than 100 mg/day and less than that in moderate to

severe CKD

•Gradual upward titration of the maintenance dose,

which can exceed 300 mg daily even in patient

with CKD

Khanna D, et al. Arthritis Care Res. 2012;64:1431-1446.

Riedel AA, et al. J Rheumatol. 2004;31:1575-1581.Chao J, et al. Curr Rheumatol Rep. 2009;11:135-140. Terkeltaub R. Recent Advances in Difficult-to-Treat Gout: Medscape ACR 2008 Annual Mtg; San Francisco, CA

ALLOPURINOL•Most common ULT in US

•Pruritic rash in ~2%; intolerance in 5%-10%

(eg, hepatic enzyme elevation, GI, CNS)

•Major cutaneous reactions (SJS, TEN) linked with HLA-

B58

•Major allopurinol hypersensitivity syndrome has

incidence of 0.1%-0.4%, up to 25% mortalityGI, gastrointestinalCNS, central nervous systemSJS, Stevens-Johnson syndromeTEN, toxic epidermal necrolysis

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Chao J, et al. Curr Rheumatol Rep. 2009;11:135-140. Zhang W, et al. Ann Rheum Dis. 2006;65:1312-1324.

ALLOPURINOL DOSING GUIDELINES

ACR, EULAR and FDA Guidelines

• Start at 100 mg daily, lower in CKD

• Increase by 100 mg daily every 2 weeks until the target SUA level is reached

• ~400 mg daily is an average dose to achieve target level in subjects with

preserved renal function

• Divide allopurinol dose to BID at >300 mg daily

• Allopurinol dose adjustment required in CKD

• FDA approved at doses up to 800 mg daily (monitor for toxicity)

INITIATING ALLOPURINOL

•Prior to initiation of allopurinol•HLA-B* 5801 screening - risk management

•High risk ratio• Korean with stage 3 or worse CKD

• Han Chinese

• ThaiHLA-B*5801, human leukocyte antigen

Khanna D, et al. Arthritis Care Res. 2012;64:1431-1446.

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FEBUXOSTAT(ULORIC)

• Non-purine backbone

• Selective inhibitor of xanthine

oxidase

• Primarily metabolized in the

liver

* P<.001 vs allopurinol** P<.001 vs febuxostat 40 mg and placebo*** P<.001 vs placebo1 Becker MA, et al. Arthritis Res Ther. 2010;12:R63.

2 Schumacher HR, et al. Arthritis Rheum. 2008;59:1540-1548.3 Becker MA, et al. N Eng J Med. 2005;353:2450-2461.

FEBUXOSTAT PHASE 3 TRIALS VS NONTITRATED ALLOPURINOL: PRIMARY ENDPOINT SERUM URATE <6 MG/DL

StudyFebuxostat40 mg daily

Febuxostat80 mg daily

Allopurinol300 mg daily Placebo

CONFIRMS1

(6 months)45%

(n=757)67%*, **

(n=756)42%

(n=755) --

APEX2

(6 months) --76%*

(n=267)41%***

(n=268)1%

(n=134)

FACT3

(12 months) --53%*

(n=256)21%

(n=253) --

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FEBUXOSTAT DOSING

•Label: 40 mg daily for 2 weeks. If serum urate does not

normalize after 2 weeks, increase to 80 mg daily

•Dose reduction not needed in moderate renal or liver

impairment (CrCL >29 ml/min)

•Most common side effects: rash (~2%), elevated LFTs

(up to 3%), and arthralgia (~1%)

• In Europe, max dose is 120; as per ACR, can titrate to

120, off label in USA LFTs, liver function tests

PRESERVATION OF RENAL FUNCTION WITH FEBUXOSTAT

-12

-10

-8

-6

-4

-2

0

2

4

6

0.5 1 1.5 2 2.5 3 3.5 4Expected Decline,untreated hyperuricemia

All Subjects treated withfebuxostat

Adapted from Whelton A, et al. Postgrad Med. 2013;125(1):106-114.

Time, y

Mea

n ch

ange

eG

FR f

rom

BL,

mL/

min

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Terkeltaub R. Nat Rev Rheumatol. 2010;6:30-38.

PHARMACOLOGIC URATE-LOWERING STRATEGIES • Uricostatic

• Suppress uric acid formation: eg, target xanthine oxidase

using allopurinol or febuxostat

• Uricosuric

• Increase uric acid elimination: eg, target proximal tubule

epithelial cell transporters using probenecid

• Uricolytic “biologic” approach

• Directly degrade soluble urate: pegloticase

DPM1

1 Reinders MK, et al. Ann Rheum Dis. 2009;68:51-56.

URICOSURIC-PROBENECID(BENEMID, PROBALAN)

• One of two FDA-approved agents currently available

• Typical dosing: 500 mg BID titrated up to 2.5 g a day

• Usage• First line if XOI can’t be used

• Second line: added to XOI if target not reached

• Not effective with eGFR <50

• Contraindicated with uric

acid overproduction

• Activity blocked by ASA

• Side effects common1

• Urolithiasis risk

• Nonspecific GI, CNS side effects

• Rash, drug-drug interactions

XOI, xanthine oxidase inhibitoreGFR, estimated glomerular filtration rateASA, aspirin

Slide 37

DPM1 Maybe this slide shoul be before teh first ALLOPURINOL slideDoghramji, Paul, MD, 3/21/2018

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LESINURAD [SINGLE AGENT)(ZURAMPIC)

Uricosuric

SURI (selective uric acid reabsorption

inhibitor)

•Approved as add-on therapy or as a single

dual action/combination product (DUZALLO)

DPM2

GETTING TO GOAL:COMBINING URATE LOWERING THERAPIES

•Many on XOI’s do not achieve <6 mg/dL or <5 mg/dL

•Medical need for additional options

•Consideration may be given to “combination therapies”

of meds with differing MOA

Slide 39

DPM2 If we put brand name here, don't we have to put brand name for all the meds?Doghramji, Paul, MD, 3/21/2018

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LESINURAD + ALLO-INCREASE IN PATIENTS ACHIEVING SUA <6 MG/DL AT MONTH 6

0%

10%

20%

30%

40%

50%

60%

CLEAR 1 (n=603) CLEAR 2 (n=610)

Placebo + ALLO

Lesinurad 200 + ALLO

28%

54%

23%

55%

EN

DP

OIN

TP

ropo

rtio

n of

pat

ient

s ac

hiev

ing

sUA

<6m

g/dL

at M

onth

6

Lesinurad Prescribing Information; Ironwood.

P<0.0001

LESINURAD+ALLO EFFICACY IN PATIENTS WITH MILD OR MODERATE RENAL IMPAIRMENT- CONSISTENT WITH OVERALL TRIAL POPULATION

0%

10%

20%

30%

40%

50%

60%

70%

60- <90 mL/min 45- <60mL/min

Placebo + ALLO

Lesinurad 200 + ALLO29%

57% 59%

32%

EN

DP

OIN

TP

ropo

rtio

n of

pat

ient

s ac

hiev

ing

sUA

<6m

g/dL

at M

onth

6

Lesinurad Prescribing Information; Ironwood.

P<0.0001

Baseline renal function

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LESINURAD PLUS FEBUXOSTAT: CRYSTAL

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Primary Secondary-Complete Resolution oftophus

Secondary-50% resolution

%

Placebo + Febuxostat Lesinurad 200 + Febuxostat 80mg Lesinurad 400mg + Febuxostat 80mg

Primary Endpoint: % of patients achieving sUA Secondary: 1. Complete resolution of tophus ;

2. 50% resolution of tophus

LESINURAD AND LESINURAD/ALLOPURINOL COMBINATION- SAFETY INFORMATION

•Risk of acute renal failure- more common when used

without a XOI

•Lesinurad should always be used in combination with

a XOI

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LESINURAD AND LESINURAD/ALLO DOSING

• One 200mg lesinurad tablet daily in combination with an XOI, including allopurinol or febuxostat

• Lesinurad/Allo combos: Lesin 200/Allo 200, Lesin 200/Allo 300

• Requires no dose adjustment for:

• Mild or moderate renal impairment (CrCl 45 mL/min)

• Moderate to severe (CrCl 30-45 mL/min- do not initiate

• Severe renal impairment (CrCl / -

• End-stage renal disease- contraindicated

Duzallo PI. Ironwood

URICOSURICS: OTHERS

•Losartan, fenofibrate, atorvastatin: •All off label•Good added options in hyperlipidemia and hypertension if indicated

•Relatively weak effects

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PATIENTS AND PROVIDERS VIEW GOUT DIFFERENTLY

• Providers view gout medication adherence as good - providing excellent relief

• In actuality, gout medication adherence is poor

• Less than 36%

• Patients discontinue gout meds

• Patients think ULT worsens or has no impact on gout

• Do not recognize long-term value

• DC therapy due to clinical and cost concerns

• Patients don’t understand the concept of ‘treatment goal’

Reach G. Joint Bone Spine. 2011;78:456-459. Harrold LR, et al. Chronic Illn. 2010 6:263-271.Coburn BW et al. Target Serum Urate- Do Gout Patients Know their Goal? 2016 Arth Care Res68(7):1028-35.

DC, discontinueULT, urate lowering therapy

DIET RECOMMENDATIONS

• Weight loss or 5%-10% goal

• Reduce or eliminate alcohol

• Drink lots of water and/or other non-alcoholic fluids

• Increase low- or non-fat dairy

• Increase plant-based proteins

• Beans, legumes

• Avoid high-purine foods

• Organ meats

• Oily fish

• Asparagus/cauliflower

• Mushrooms ACR Recommendations and Healthline

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THE ECONOMICS BEHINDACHIEVING GOUT GOALS

Year Study Authors Title Factor Cost

2013 Rao S, Haji A, Burns L, Choi H The Economic Burden of Gout: A Systematic Review of Direct and Indirect Costs(Boston U. and Univ. of British Columbia)

-Work productivity loss with >3 flares/yr-Gout related healthcare costs with 6+ flares/yr

$ 2,000+ per patient$ 12,000+ per patient

2015 Rai SK, Lindsay CB, De VeraMA, Haji A, Giustini D, Choi HK

The Economic Burden of Gout: A systematic review

All-cause direct costs• Employed• Elderly• Treatment-refractory

Gout Non-gout$ 4,400 $ 2,560$ 17,000 $10,600$ 18,400 $ 7,200

2016 Lim Sy, Lu N, Oza A, Fisher M, Rai SK, Menendez ME, Choi HK

Trends in Gout & Rheumatoid Arthritis Hosps. In the US- 1993-2011

-Inflation-adjusted annual hospitalization costs for gout (+68%)• Gout admissions

$ 58,003

• Preventable-inadequate or inefficient care

KNOWLEDGE GAPS IN PATIENTS

• Clear understanding of progression

• Untreated elevated SUA results in chronic joint damage

• Treatment options and duration of therapy for acute and chronic gout

• Concept of ULT to avoid complications and disability

• Treatment ‘goals’

Khanna P et al. Knowledge Gaps In Patients with Gout- A Qualitative Study. 2012 ACR/ARHP Annual Meeting.Coburn BW et al. Target Serum Urate- Do Gout Patients Know their Goal? 2016 Arth Care Res68(7):1028-35.

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PATIENT ENGAGEMENT

•Accountability starts

with an informed patient

• Improves patient satisfaction

with therapy decision

•Promotes adherence to

therapeutic regimen

and medication

PATIENT EDUCATION GOALS IN GOUT

• Patients want to know more1

• Causes of gout

• Treatment goals

• Long-term consequences

• Exercise for overall health, joint

mobility, and weight maintenance2

• Diet

• Medication adherence tips

1. Onna M, Hinsenveld E, de Vries H, Boonen A. Health Literacy in patients dealing with gout. 2015 Clin Rheumatology 34(9):1599-603.2. Khanna D, et al. Arthritis Care Res. 2012;64:1431-1446.

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PHYSICAL ACTIVITY GOALSCDC 2015

• Arthritis improves with physical activity

• Adult goals

• 150 minutes moderate-intensity/week plus

• Muscle strengthening 2 or more days/week

• Older adult goals

• 150-300 minutes moderate-intensity/week plus

• Muscle strengthening 2 or more days/week

• Physical disability

• Refer to physical therapistCDC 2015 Gout Goals www.cdc.gov

ACR: DIET RECOMMENDATIONS

Avoid Limit Encourage

• Organ meats high in purine content (sweetbreads, liver, kidney)

Serving sizes of:• Beef, Lamb, Pork• Seafood with high purine content

(sardines, shellfish)

• Low-fat or non-fat dairy products

• High fructose corn syrup - sweetened sodas, other beverages, or foods

• Servings of naturally sweet fruit juices• Table sugar, and sweetened beverages

and desserts• Table salt, including in sauces

and gravies

• Vegetables, Cherries

• Alcohol overuse (defined as more than 2 servings per day for a male and 1 serving per day for a female) in all gout patients

• Any alcohol use in gout during periods of frequent gout attacks, or advanced gout under poor control

• Alcohol (particularly beer, but also wineand spirits) in all gout patients

B B B

C C C

C

BB

Khanna D, et al. Arthritis Care Res. 2012;64:1431-1446.

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MANAGING THE GOUT PATIENT LONG-TERM•Prevent gout attacks with prophylaxis flare therapy for

first 3-6 months of ULT

•Maintain normal serum UA with long-term ULT medication

•Support diet and lifestyle modifications

•Monitor side effect status of flare medication

•Measure SUA levels regularly (~every 6 months)

•Monitor ULT side effects

•Monitor renal function SUA: serum uric acidULT: urate lowering therapy

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WHAT TOP PRACTICE CHANGEWILL YOU IMPLEMENT

OVER THE NEXT 3 MONTHS?

1. Place gout on the practice ”radar” by incorporating a “treat-to-target” approach reinforced by practice enhancements and training

2. Utilize pharmacologic combinations to increase numbers of patients reaching goal

3. ‘Set’ and ‘Implement’ sUA goals- education and discussion with both patients and the practice TEAM

4. Consider adding or switching medication when sUA goals are not achieved

5. Follow-up patients through office monitoring every 6 months to assess adherence and goal achievement

APPROXIMATELY HOW MANY GOUT PATIENTS (IN STUDIES) ACHIEVE URIC ACID GOAL OF <6.0 MG/DL?1.90%

2.80%

3.70%

4.60%

5.Less than half

6.Unsure

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URATE LOWERING THERAPY (ULT) USUALLY EXTEND OVER WHAT PERIOD OF TIME?

1.3 months

2.6 months

3.1 year

4.Remainder of life

5.Unsure

WHAT IS CONSIDERED TREATMENT “SUCCESS” FOR A GOUT PATIENT?

1. Relief of flare pain

2. Reduction in flares

3. Reduction in uric acid

4. Reduction in uric acid to <6.0mg/mL or <5.0mg/mL

5. 1 & 2

6. 1, 2 & 3

7. 1, 2 & 4

8. 2 & 4

9. Unsure

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1. A beer binge

2. Ingestion of large quantities of seafood

3. Reduced kidney function

4. Hyperuricemia

5. A sore toe

6. All of the above

7. Unsure

THE PRECIPITATING FACTOR IN A FIRST ACUTE EPISODE OF GOUT IS USUALLY: (CHOOSE BEST ANSWER)

GETTING PATIENTS TO GOAL IS DIFFICULT. IF A PATIENT DOES NOT ACHIEVE GOAL, FURTHER CONSIDERATION SHOULD BE GIVEN TO: (SELECT THE BEST CHOICE)

1. Complete reduction of alcohol

2. Weight loss

3. Bland diet

4. Stronger anti-inflammatories

5. Increased exercise

6. Combination therapies

7. Unsure

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Paul P. Doghramji, MD, FAAFP