Practical application of national clinical guidelines for the management of gout (preliminary data)

Abstract

The 2018 national guidelines for the management of gout provide a consistent scheme for urate-lowering drugs; however, the possibility of achieving uric acid (UA) targets in its use has not been studied.Objective: to evaluate the effectiveness and safety of the urate-lowering therapy algorithm presented in the national guidelines for the management of gout.Patients and methods. This investigation was a prospective single-center study. It has been currently included 54 patients (91% males) with gout. The follow-up period is not less than 12 weeks of continuous use of allopurinol or febuxostat (Azurix) at the final dose.After the initiation of urate-lowering therapy, allopurinol 100 mg/day was prescribed, followed by dose titration to achieve the UA target that was defined as <360 or <300 μmol/L in patients with severe tophaceous gout. The maximum dose was 900 mg/day; it was 300 mg/day when the glomerular filtration rate was <60 ml/min/1.73 m2 . Patients with the inefficacy of allopurinol and/or the presence of its associated adverse reactions (ARs) were prescribed febuxostat 80 mg/day; the dose was increased to 120 mg/day as needed.For the prevention of acute arthritis attacks, all the patients received a nonsteroidal anti-inflammatory drug (NSAID) at the minimum therapeutic doses or colchicine 0.5 mg/day, and if these drugs were contraindicated, a glucocorticoid (GC) 7.5 mg/day, as calculated with reference to prednisone, was taken.The probability of achieving the serum UA target (<360 or 300 μmol/L) was assessed in patients with chronic tophaceous gout.Results and discussion. 12 weeks after therapy initiation, the UA target could be achieved in 39/50 (79%) patients. The target levels <360 and 360 μmol/L were recorded in 15/21 (71%) and 24/33 (73%), respectively. The UA level <360 μmol/L was noted to decrease in a total of 92% of cases. Febuxostat was given to 41 patients: to 27 (66%) due to the inefficacy of allopurinol and to 14 (34%) due to its ARs. As a result, the UA target was achieved in 30 (73%) patients, and there was a decrease in the UA level <360 μmol/L in 35 (85%).ARs were seen only in 3 febuxostat-treated patients, including 2 patients with previous allopurinol-induced ARs.For the prevention of arthritis attacks, 10 (19%) patients took NSAIDs, 41 (75%) received colchicine, and 3 (6%) used GC. There were no refusals to receive urate-lowering and preventive anti-inflammatory therapies.Conclusion. The proposed treatment regimen allows for achieving the serum UA target in 79% of patients and its decrease <360 μmol/L in 92%. Treatment with febuxostat (Azurix) is associated with its good tolerance, including in the patients who could not use allopurinol because of AR. Preventive anti-inflammatory therapy is likely to improve adherence to urate-lowering therapy.

Commentaries on the updated American College of Rheumatology guidelines for the management of gout. Urate-lowering drugs (Part 1)

“…Через 3 мес терапии уровень МК <360 мкмоль/л был достигнут у 35 (85%) из 41 пациента. Нежелательные реакции при применении препарата наблюдались крайне редко -всего у 3 пациентов, в том числе у 2 с наличием таковых при предшествующем приеме аллопуринола [53]. В целом применение предложенной схемы лечения позволяло достичь ЦУ МК сыворотки у 79% пациентов, а снижения МК <360 мкмоль/л -у 92%.…”

ACR management guidelines for the treatment of gout: What’s new and what’s controversial

“…С другой стороны, не вызывает сомнения включение в перечень возможных способов профилактики приступов нестероидных противовоспалительных препаратов (НПВП) и глюкокортикоидов (ГК). Если же использовать для профилактики приступов только низкие дозы колхицина, как предлагают рекомендации Французской ассоциации ревматологов [13], то значительная часть пациентов в силу наличия плохой переносимости или противопоказаний не смогут его принимать [27]. При этом низкие дозы НПВП и ГК могут быть альтернативой колхицину, в том числе когда его использование невозможно [28,29].…”

The place of febuxostat in the treatment of gout

“…Таким образом, сегодня было бы неправильно отрицать необходимость применения аллопуринола в качестве препарата первой линии у пациентов с подагрой. В то же время рассматривать фебуксостат исключительно как препарат резерва можно лишь условно, учитывая неэффективность аллопуринола, в том числе при назначении в максимальных дозах, и необходимость минимизации его дозы в случаях нарушения функции почек [48,49]. В такой ситуации у пациентов с наличием неэффективности или аллергическими реакциями (в том числе тяжелыми кожными) на аллопуринол в анамнезе, частота которых довольно высока, целесообразность применения фебуксостата не вызывает сомнений.…”