The most common mistake in gout management
One of the most common treatments for chronic gout can actually prolong acute attacks.
Gout can be tricky to diagnose and treat, in part because uric acid blood levels can actually be normal during an attack; it’s a change in uric acid level—not necessarily an increase—that provokes the acute symptoms. Some drugs your doctor prescribes for other conditions can even cause gout attacks, such as those given after organ transplants.
Dr. Clement Michet, consultant in rheumatology at the Mayo Clinic in Minnesota, has encountered a lot of gout in his 30 years of practicing medicine. “Patients usually seek medical care somewhere because it is incredibly painful, but the issue I see, and I am at the end of a big funnel, is that gout is under-treated. It’s an all too common problem, and people are also often confused about their medications—when to take what, when not to take a pill.”
Dr. John Pappas, medical director and principal investigator at Lexington’s Kentucky Medical Research Center, has also been treating gout for over 30 years. He describes it as a relatively easy diagnosis to make, mainly due to the severity of the pain. “The severity is akin to childbirth or a broken bone,” he says. “Gout is an under-diagnosed and under-treated disease, and it certainly has health implications for those patients who are not treated properly. Their lives would quite possibly be improved if adequate treatment was given.”
"The diagnosis is not difficult to make if patients present with the prototypical pain in their large toe, thumb or a specific joint," agrees CEO of New Horizons Clinical Research Dr. Gregory M. Gottschlich, who has been conducting clinical trials with various medications for years, and has also encountered patients with gout in his clinical practice. "But often times it is diagnosed but not necessarily treated with any sense of urgency or great concern by a large number of physicians, and it is sometimes discounted by patients as well. It is trivialized. Some physicians don’t pay enough attention to the link between gout and other diseases such as hypertension, diabetes and metabolic syndrome."
Acute vs. long-term treatment
The most commonly prescribed medicines for long-term prevention of gout are allopurinol and febuxostat, but they do not treat gout attacks, explains Dr. Michet, noting that some patients, in error, only take allopurinol when experiencing an attack. “If you do this, you are changing the uric acid levels in your blood, thus prolonging an attack. There is a real need for education about appropriate gout treatment.”
“If you treat an acute gout attack and the attack subsides, patients might stop the therapy that could prevent another gout attack,” explains Dr. Pappas. “If someone has a gout attack, there is almost a 90% chance they will have another. Certain medications to lower uric acid can virtually prevent attacks from occurring, but often people just treat the symptoms rather than the underlying cause.”
The extent of mismanagement prevalent in the treatment of gout is widespread among both lay persons and medical professionals.
To lower acid levels and substantially reduce the likelihood of having further attacks or long-term joint damage, you must treat the underlying cause of gout. Often gout patients are on multiple medications for other comorbidities such as hypertension. “Patients are often taking five, six even seven medications. They often like to cut out medicines that they don’t feel are necessary. I can empathize with someone wanting to stop taking all that medicine, but gout is a highly treatable disease, and we know the pathophysiology. We can substantially reduce the clinical symptoms and side effects,” explains Dr. Pappas.
It is crucial that patients comply with their doctor’s instructions, but also that they see a doctor who is well educated about gout’s different stages:
- Asymptomatic Hyperuricemia: The patient has elevated levels of uric acid but no symptoms
- Acute Gout Attack: A symptomatic flare-up accompanied by severe pain
- Intercritical Gout: The symptom-free period in between gout attacks
- Chronic Gout: Chronic arthritis accompanied with destructive symptoms such as bone and cartilage damage and possible kidney damage
During the intercritical period, uric acid crystals can remain within joint fluid, damaging the joints and other organs, even in the absence of an acute flare-up, explains Dr. Pappas. “These stages are not intercritical, but rather critical. It is critical you still take medication to keep uric acids low and to prevent organ damage.”
Dr. Michet urges patients to ensure their diagnosis is correct. “If gout is not treated properly, other types of arthritis can occur.” He also suggests discussing other risk factors with your doctor. “The first episode of gout is a great opportunity to review blood pressure, lipids, blood sugar and other metabolic risks that need to be addressed simultaneously.”
“Even some doctors will prescribe allopurinol to patients when they experience a gout attack, which is not good,” notes Dr. Yuqing Zhang, professor of medicine & public health at Boston University’s School of Medicine. As Zhang’s statement makes clear, the extent of mismanagement prevalent in the treatment of gout is widespread among both lay persons and medical professionals. It is important that gout sufferers—and potential sufferers—educate themselves about this serious disease and the best ways for treating and managing it.