I was asked by the organizers to review updates on the management of gout. I compared guideline recommendations from the 2008 Philippine CPG to the 2012 ACR Recommendations and the 2014 3E Initiative.

1. REVISITING GOUT
Updating the Recommendations
Sidney Erwin T. Manahan, MD FPCP FPRA
21st PRA Annual Meeting - PRECONVENTION
26 February 2015

2. DISCLOSURES
• Module developer for Pfizer (Celebrex)
• Member, Speakers’ Bureau for Pfizer (Celebrex, Lyrica)
• Honoraria for talks given on behalf of Ajanta Phils
(Atenurix) and Roche (Actemra)
• Participated in drug trials as sub-investigator/ co-
investigator for Roche, Wyeth, Parexel (Janssen) and
Novartis

3. Disease Manifestations

4. Natural Course of Disease
0 10 20 30
Duration of Hyperuricemia (Years)
7
14
LevelofHyperuricemia(mg/dl)
Asymptomatic
ACUTE GOUT
INTERVAL GOUT
CHRONIC
GOUT

5. OBJECTIVE
Provide updates to recommendations made by the
2008 Philippine Clinical Practice Guidelines on the
Management of Uncomplicated Gout
Philippine
CPG
ACR
2012
3E
Initiative
Khanna D, et al. 2012 ACR Guidelines for
Management of Gout (2 parts). Arth Care & Res 2012
64 (10): 1431-61.
Sivera F, et al. Multinational Evidence-Based
Recommendations for the Diagnosis and Management
of Gout. Ann Rheum Dis 2014; 73: 328-35.
Li Yu J, et al. Philippine Clinical Practice Guidelines on
the Medical Management of Uncomplicated Gout. Phil
J Int Med 2008.

6. Gout Classification Criteria
Criteria Categories Score
Clinical Pattern of Involvement Ankle / midfoot 1
MTP1 2
No of episodes ever One 1
Two 2
Three 3
Time Course One typical 1
Recurrent 2
Clinical Tophus Present 4
Laboratory Serum uric acid 6-8mg/dl 2
8-10mg/dl 3
>10mg/dl 4
Imaging US or DECT Present 4
Xray erosion Present 4

7. Treatment Objectives
Asymptomatic
Phase
ACUTE
GOUT
INTERVAL
GOUT
CHRONIC
GOUT
Terminate
the Attack
Prevent recurrent attacks
Prevent/reverse complications
Prevent the
1st Attack
Lower serum uric acid to target

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10.          
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         
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11. Asymptomatic
Hyperuricemia
>7mg/dl (M)
>6mg/dl (F)
Hypertension
CV Disease
Stroke
Renal Disease
Metabolic
Syndrome
CAUSE
RESULT
?

12. Asymptomatic Hyperuricemia
Philippine
CPG
ACR
2012
3E
Initiative
NO RECOMMENDATION due to paucity of
prospective trials
Pharmacologic treatment is NOT recommended
to prevent gout, renal or cardiovascular disease
Do NOT routinely treat with Allopurinol
Address conditions associated with
hyperuricemia
CAVEAT
Serum uric acid >11-13mg/dl (Nephrolithiases)
Tumor lysis syndrome
Prevent CKD Stage 2-3 progression

13. Treatment Objectives
Asymptomatic
Phase
ACUTE
GOUT
Terminate
the Attack
Prevent the
1st Attack

14. Philippine
CPG
ACR
2012
3E
Initiative
Colchicine
NSAIDs/
COXIBs
Steroids
Colchicine
NSAIDs/
COXIBs
Steroids
Colchicine
NSAIDs/
COXIBs
Steroids
Acute Gout
Patient Preference  Experience  Comorbid Disease
Combination
Therapy

15. Recommended Drugs in Acute Gout
Colchicine
NSAIDs/
COXIBs
Steroids
1mg then 0.5mg TID
12h later
Full anti-
inflammatory dose
Prednisone 1mkd x 2-
5days the taper x7d
Prednisone 0.5mkd for
5-10 days
Triamcinolone 60mgIM
IA Steroids

16. CAUTION!
CONDITIONS Colchicine
NSAIDs/
COXIBs
Steroids
Chronic renal disease X X
Heart failure X
Peptic ulcer disease X X
Anticoagulants X
Diabetes mellitus X
Infections X
Liver disease X X
Khanna D, et al. 2012 ACR Guidelines for Management of Gout (2 parts). Arth Care & Res 2012 64 (10): 1431-61.

17. Pain VAS <6/10 OR
Few small joints OR
1 -2 large joints
Pain VAS >6/10 OR
Polyarthritis OR
1 -2 large joints
OPTIONS
• Colchicine
• NSAIDs / COXIBs
• Steroids
COMBINATION
THERAPY
Start treatment w/in
24 HOURS
RESPONSE?
>20% in 24h OR >50% after 24h

18. Treatment Objectives
Asymptomatic
Phase
ACUTE
GOUT
INTERVAL
GOUT
CHRONIC
GOUT
Terminate
the Attack
Prevent recurrent attacks
Prevent/reverse complications
Prevent the
1st Attack
Lower serum uric acid to target

19. Philippine
CPG
ACR
2012
3E
Initiative
Colchicine Colchicine
NSAIDs/
COXIBs
Steroids
Prophylaxis Duration
Colchicine
NSAIDs/
COXIBs
Steroids
No Gout
Flares
• 6 months of target SUA
• 3 months of target SUA if without tophi
• 6 months of target SUA and resolution of
documented tophi

20. WHEN TO START
URATE-LOWERING THERAPY
Philippine
CPG
ACR
2012
3E
Initiative
COULD be started during an acute gout attack
provided effective anti-inflammatory therapy has
been instituted
NO CONSENSUS. Incidence of flare reflected
rate of urate lowering. Start low, go slow in giving
urate lowering therapy
10-14 days after flare resolution

21. INDICATIONS
for Urate Lowering Therapy
• At least 2 flares/year
• Presence of tophi
• Radiographic changes of
arthropathy
• Nephrolithiases
• Co-morbid conditions that may
complicate treatment of gout (CV
disease, CKD)

22. Philippine
CPG
ACR
2012
3E
Initiative
<6mg/dl
Reduce attacks
Prevent tophi
Target Serum Uric Acid
<6mg/dl
For most
patients
<6mg/dl
Reduce attacks
Prevent tophi
<5mg/dl
If with tophi
<5mg/dl
Reduce attacks
Dissolve tophi
Dissolve crystals

23. Philippine
CPG
ACR
2012
3E
Initiative
LONG
TERM
Duration of Urate Lowering Therapy
LONG
TERM
LIFE
LONG
• Treat hyperuricemia but not the cause
• Discontinuing ULT resulted in recurrence
• Depletion of stores after 5 years of target SUA

24. Philippine
CPG
ACR
2012
3E
Initiative
Allopurinol
Choice of Urate Lowering Therapy
Allopurinol
Febuxostat
Losartan,
Fenofibrate
Uricosurics
Allopurinol
Losartan,
Fenofibrate
Uricosurics
Febuxostat

25. Start
PRIMARY DRUG
Is drug
TOLERATED?
Was target SUA
ACHIEVED?
MONITOR
Shift to other drug
Titrate up
SUA, creatinine,
LFTs
ALLOPURINOL
100mg OD*
Tolerated
Not Achieved
Monitor every
titration
Not tolerated
Add losartan or
fenofibrate
Monitor 3-6
months once
stable dose
Continue
Titrate by 100mg*
q 2-4 weeks
(max 900mg)
Shift to
Febuxostat
* Dose adjustment in
renal impairment (50mg)

26. Start
PRIMARY DRUG
Is drug
TOLERATED?
Was target SUA
ACHIEVED?
MONITOR
Shift to other drug
Titrate up
SUA, creatinine,
LFTs
FEBUXOSTAT
40mg OD
Tolerated
Not Achieved
Monitor every
titration
Not tolerated
Add losartan or
fenofibrate
Monitor 3-6
months once
stable dose
Continue
Titrate by 40mg q
2-4 weeks
(max 120mg)
Shift to Allopurinol
No adjustment in
mild moderate
renal impairment

27. Which is BETTER?
100mg
200mg
300mg
400mg
500mg
600mg
700mg
800mg
40mg
80mg
120mg
240mg
Tayar JH, et al. Febuxostat for treating chronic gout. Cochrane Database of Systematic
Reviews 2012; Issue 11. Art No. CD008653. DOI: 10.1002/14651858.CD008653.pub2
No Statistical difference in
Incidence of Gout Flares
Rates of adverse events
Discontinuation
CONVENIENCE
FEBUXOSTAT ALLOPURINOL

28. Lifestyle Changes in Gout
Exercise /
Weight
management
Adequate
Hydration
Smoking
Cessation
Diet

29. Dietary Recommendations Pre 2008

30. Diet Choices in Gout: MODERATION
AVOID
• Organ/ red meats
• Drinks with fructose
(corn syrup)
• Alcoholic drinks
LIMIT
• Seafood
• Sweetened fruit
juices
ENCOURAGE
• Dairy Products
• Vegetables

31. Let’s treat Gout
BETTER!
• Identify the stage of disease
• Set goals appropriate for stage
• Give proper advice and treatment
• Educate our patients
• Monitor and follow-up regularly

32. CALL A FRIEND
Your friendly neighborhood
RHEUMATOLOGIST
• Refractory gout
• Difficulty in achieving target SUA
• Multiple or serious adverse events

33. THANK YOU!