Sharing Decisions in Gout: Better Communication for Better Outcomes

ABSTRACT: More effective communication can improve both adherence to and outcomes of gout treatment regimens. All patients should share with their physician a commitment to maintaining a serum urate concentration lower than 6 mg/dL. More important than limitation of exogenous, dietary purines is restriction of constituents that accelerate endogenous purine synthesis. An arthrocentesis often is useful in therapy and always is desirable for diagnosis. Improved understanding may help clinicians and patients overcome reluctance about aspiration. Patients must recognize that flares become more likely as hyperuricemia comes under control and that prophylactic anti-inflammatory therapy may be needed throughout this period of increased risk. Patients often remain uncertain about how or why they should take each medication for their gout. (J Musculoskel Med. 2008;25:116-123).

Gout stands virtually alone among the chronic rheumatologic diseases in that it has a pathognomonic diagnostic test, a reasonably well-understood pathogenesis,and an array of effective therapeutic interventions.^1,2 In spite of these positive aspects, gout frequently is undertreated and mistreated.

Many failures in gout management may be attributed to miscommunication between harried physicians and their busy, seemingly recovering male patients. Both parties to physician-patient interactions need to recognize gout as a progressive condition, one that almost always can be controlled readily at its outset but without such control too often becomes more and more refractory and disabling as the years of neglect go by.

Once established, gout will remain a constant companion for the remainder of the patient’s life. Whether that presence is the pale shadow of well-controlled hyperuricemia or the vicious demon of chronic, tophaceous disease often is determined by the patient’s degree of adherence to a well- designed program. In this article, I address key issues in gout management and discuss how more effective patient-physician communication can improve adherence and medical outcomes.

MAINTAINING THE SERUM URATE LEVEL

The simple principle of crystal precipitating from supersaturated body fluids underlies the understanding of gout and much of its management. Every patient should know this principle well and should share with his or her physician a commitment to attaining and maintaining a serum urate concentration lower than 6 mg/dL (Figure).

Figure – To help patients with gout learn what they need to know about managing their condition, physicians may provide them with a simple form such as the one shown here. The physician can duplicate the form as needed, and each patient can complete it with the physician and then hang it on the inside of his or her medicine cabinet door for easy reference.

This number is not arbitrary. It is based on the known solubility of urate in saline at 37°C (98.6°F)—about 6.8 mg/dL, the low risk of new arthritis in non-gouty patients below this level,³ and the demonstrated resolution of tophaceous deposits when hyperuricemia is controlled.⁴

What matters here is the long-term picture. The serum urate level often falls during acute episodes of arthritis, and low values at such times cannot be taken as evidence against gout or for effective control. Conversely, a higher value (say, about 6.4 mg/dL) may introduce an element of concern, but it need not cause a change in program for a patient who otherwise is doing well. However, sustained levels higher than 7 mg/dL imply a clear probability of ongoing crystallization, as well as the impossibility of mobilizing existing tophaceous deposits.