November 10-15

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ACR Convergence 2023

San Diego, CA


Home // New ACP guideline leads to debate about changing gout management plans

New ACP guideline leads to debate about changing gout management plans

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5 minutes

An ACR symposium on Monday will update attendees on some important issues in gout treatment, including the recent publication of the American College of Physicians (ACP) gout treatment guideline, recommended best practice strategies for optimal imaging in gout, and recent advances in asymptomatic hyperuricemia and associated pathophysiology.

The symposium, Controversies in Diagnosis & Mgt of Gout & Asymptomatic Hyperuricemia, will be held on Monday from 2:30 – 4:00 pm in Hall B1.

Tuhina Neogi, MD, PhD, FRCPC
Tuhina Neogi, MD, PhD, FRCPC

Tuhina Neogi, MD, PhD, FRCPC, will talk about the new ACP guideline, which challenges several key aspects of optimal gout management as practiced now by most gout experts. The new ACP guideline proposes a treat-to-symptoms approach — guidance that Dr. Neogi, Professor of Medicine at the Boston University School of Medicine and Professor of Epidemiology at the Boston University School of Public Health, believes could potentially lead to undertreatment of gout in primary care practices.

“Globally, all scientific rheumatology associations in their gout treatment guidelines support a treat-to-target approach, which refers to treating hyperuricemia, the underlying cause of gout,” Dr. Neogi said. “The ACP has taken a different approach, contending that specific threshold targets for lowering uric acid have not been tested in randomized controlled trials and, further, that it has not been shown that lowering uric acid actually leads to clinically important endpoints for patients.”

Regarding the first contention, Dr. Neogi said it’s true that randomized controlled trials have not demonstrated an optimum target level for lowering uric acid but noted that there is clear science and clinical consensus to support approximate threshold levels.

“Based on our understanding of the biology, we know that you want to get the uric acid level below the saturation point at which it begins to crystallize, which is 6.8 (mg/dL),” she said. “Most rheumatology associations recommend lowering uric acid to at least below 6; some recommend lowering it to even less than 5, particularly in patients who have a large urate burden.”

As to the second contention, Dr. Neogi believes the ACP guideline fails to consider strong evidence suggesting that lowering uric acid improves outcomes, such as the pegloticase trials, which she said demonstrated that lowering uric acid to below 6 was associated with greater tophus resolution and a statistically significant reduction in gout flares.

Ralf G. Thiele, MD, RhMSUS
Ralf G. Thiele, MD, RhMSUS

Ralf G. Thiele, MD, RhMSUS, will follow with a discussion on emerging data on the role of advanced imaging, specifically ultrasound and dual-energy CT (DECT), in the diagnosis and management of gout.

“Ultrasound is a technology that rheumatologists have really picked up quite a bit over the last ten years or so in the U.S., and many rheumatologists actually have it in their practice,” said Dr. Thiele, Associate Professor of Medicine in the Division of Allergy/Immunology and Rheumatology at the University of Rochester School of Medicine in New York. “Ultrasound has advantages over conventional radiography in identifying typical features of gout, such as inflammation and the presence of gouty tophi and helping with a diagnosis.”

Dr. Thiele said ultrasound imaging also provides a convenient tool for monitoring disease progression and the effectiveness of treatment for rheumatologists who have the ability to perform it in their practices. DECT is a newer modality that offers comparable benefits for diagnosing and monitoring patients with gout, but may not always be as convenient or accessible as ultrasound.

“The other downsides of DECT are cost — it’s more expensive than ultrasound — and the risks associated with radiation exposure,” Dr. Thiele said. “On the plus side, we often get very nice images with DECT that we can view and manipulate in 3D. We can virtually turn the joints around on our computer screen and look for deposits of uric acid crystals.”

MIchael Pillinger, MD
Michael Pillinger, MD

Michael Pillinger, MD, will discuss the current understanding of the impact of hyperuricemia in the absence of gout. Dr. Pillinger is Professor of Medicine, and Biochemistry and Molecular Pharmacology at New York University School of Medicine and Chief of Rheumatology at the Manhattan Campus of the New York Harbor VA Health Care System in New York City.

“Besides being the predisposing factor for gout, hyperuricemia is, in fact, a lot more common than gout as met by clinical criteria,” Dr. Pillinger said. “The prevalence of gout in the general population is about four percent, while it is upwards of 20 percent for hyperuricemia. That’s a lot of people.”

While the majority of current evidence on hyperuricemia comes from studies involving gout patients, Dr. Pillinger said there is growing evidence suggesting the adverse effects of asymptomatic hyperuricemia.

“When we use ultrasound, a significant percentage of asymptomatic hyperuricemic patients are shown to have urate crystals on some of their cartilage and joints,” Dr. Pillinger said. “And it’s not just the actual crystallization, but there may be biochemical impacts of non-crystallized urate as well. There are in vitro and animal models, for example, to suggest that there are impacts on the vasculature that may contribute to cardiovascular disease in hyperuricemics.”

He said some data suggest that lowering urate in non-gout patients with kidney disease reduces the disease’s rate of progression.

“Additionally, my research group recently published a paper in which we reported data suggesting that urate may even be a marker for the progression of osteoarthritis,” Dr. Pillinger said.