Gout as a new old problem faced by an outpatient care physician

Authors: Ján Gajdošík ;  Zuzana Hlavičková
Authors‘ workplace: Neštátna ambulancia pre dospelých v Nových Zámkoch
Published in: Forum Diab 2019; 8(1): 0


Gout is a problem quite frequently encountered in outpatient care, whether by general practitioners for adults or specialized outpatient care physicians, in particular internists, nephrologists, cardiologists and oncologists. It is them who will see and treat patients with acute gout attacks within their competence the most frequently, while rheumatologists will rather see patients with gout associated complications – tophaceous gout or polyarthritic form of gout. The care of patients with gout is long-term and continuous, requiring cooperation between physicians and patient adherence. It is accompanied by a number of open issues, points lacking clarity which professional associations endeavour to address through publishing guidelines, available are recommendations from the American College of Rheumatology (ACR), 3e-initiative (Evidence, Expertise, Exchange) – international association of rheumatologists, A + NZ (Australia and New Zealand), American College of Physicians (ACP), British Society for Rheumatology (BSR). The European League against Rheumatism (EULAR) provides recommendations (the rest from 2016) that are the most frequently used in the care of patients with gout/hyperuricemia in continental Europe [1].



acute gout attack – allopurinol – colchicine – corticosteroids – gout – gout attack drugs – nonsteroidal antiInflammatory drugs – prophylactic treatment – treatment of hyperuricemia

  1. Combe B, Landewe R, Daien CI et al. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2017; 76(6): 948–959. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2016–210602>.
  2. Alušík Š., Paluch Z. Kontroverze v léčbě dny. Vnitř Lék 2018; 647(7–8): 753–761).
  3. Bardin T, Richette. Definition of hyperuricemia and gouty conditions. Curr Opin Rheumatol 2014; 26(2): 186–191. Dostupné z DOI: <http://dx.doi.org/10.1097/BOR.0000000000000028>.
  4. Mikuls TR, Farrar JT, Bilker WB et al. The treatment of asymptomatic hyperuricemia: results from the population-based general practice research database (GPRD). Arthritis Rheum 2003; 48(Suppl 9): S612-S616.
  5. Alderman MH: Podagra, Urid Acid and Cardiovascular Disease. Circulation 2007; 116(8): 880–883. Dostupné z DOI: Dostupné z DOI: <http://dx.doi.org/10.1161/CIRCULATIONAHA.107.728600>.
  6. Saag KG, Choi H. Epidemiology, risk factors, and lifestyle modifications for gout. Arthritis Res Ther 2006; 8(Suppl 1): S2. Dostupné z DOI: <http://dx.doi.org/10.1186/ar1907>.
  7. Wallace SL, Robinson H, Masi AT et al. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977; 20(3): 895–900.
  8. Růžička V. Dna. Interní Med Praxi 2003; 5(4): 173–177.
  9. Bošmansky K, Pullmann R. Dna. In: Ďuriš I, Hulin I, Bernadič M. Princípy internej medicíny. SAP Bratislava 2001: 1534–1548. ISBN 8088908698.
  10. Culleton BF, Larson MG, Kannel WB et al. Serum uric acid and risk for cardiovascular disease and death: the Framingham Heart Study. Ann Intern Med 1999; 131(1): 7–13.
  11. Rybár I. Dna – diagnostika a liečba. Via Practica 2014; 11(5): 154–158. Dostupné z WWW: <http://www.viapractica.sk/index.php?page=pdf_view&pdf_id=7140&magazine_id=1>.
  12. Růžička V. Dna. Interní Med Praxi 2003; 5(4): 173–177.
  13. Eastmond CJ, Garton M, Robins S et al. The effects of alcoholic beverages on urate metabolism in gout sufferers. Br J Rheumatol 1995; 34(8): 756–759.
  14. Hartus, E, Budd, R, Firestein, G et al. Kelley‘s Textbook of Rheumatology. 7th ed. Elsevier Saunders 2004. ISBN 0721601413.
  15. Campion EW, Glynn RJ, DeLabry LO. Asymptomatic hyperuricemia. Risks and consequences in the Normative Aging Study. Am J Med 1987; 82(3): 421–426.
  16. Choi HK, Atkinson K, Karlson EW et al. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med 2004; 35(11): 1093–1103. Dostupné z DOI: <http://dx.doi.org/1112.10.1056/NEJMoa035700>.
  17. Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ 2008; 336(7639): 309–312. Dostupné z DOI: <http://dx.doi.org/10.1136/bmj.39449.819271.BE>.
  18. Choi HK, Willett W, Curhan G. Fructose-rich beverages and risk of gout in women. JAMA 2010; 304(29): 2270–2278. Dostupné z DOI: <http://dx.doi.org/10.1001/jama.2010.1638>.
  19. Gao X, Qi L, Qiao N et al. Intake of added sugar and sugar-sweetened drink and serum uric acid concentration in US men and women. Hypertension 2007; 50(2): 306–312. Dostupné z DOI: <http://dx.doi.org/10.1161/HYPERTENSIONAHA.107.091041>.
  20. Choi JW, Ford ES, Gao X et al. Sugar-sweetened soft drinks, diet soft drinks, an serum uric acid level: the Third National Health and Nutrition Examination Survey. Arthritis Rheum 2008; 59(1): 109–116. Dostupné z DOI: <http://dx.doi.org/10.1002/art.23245>.
  21. P Richette, M Doherty, E Pascual et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017; 76(1): 29–42. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2016–209707>.
  22. Pascart T, Lancrenon S, Lanz S et al. GOSPEL 2 – colchicine for treatment of gout flares in France – a Gospel study survey subgroup analysis. Doses used in common practices regardless of renal impairment and age. Joint Bone Spine. 2016; 83(6): 687–693. Dostupné z DOI: <http://dx.doi.org/10.1016/j.jbspin.2015.10.006>.
  23. Terkeltaub RA, Furst DE, Bennett K et al. High versus low dosing of oral colchicine for early acute gout flare: twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum 2010; 62(4): 1060–1068. Dostupné z DOI: <http://dx.doi.org/10.1002/art.27327>.
  24. Yang LP. Oral colchicine (Colcrys): in the treatment and prophylaxis of gout. Drugs. 2010; 70(12): 1603–1613). Dostupné z DOI: <http://dx.doi.org/10.2165/11205470–000000000–00000>.
  25. Ben-Chetrit E, Bergmann S, Sood R. Mechanism of anti- -infl ammatory eff ect of colchicine in rheumatic disease: a possible new outlook through microaaray analysis. Rheumatology (Oxford) 2006; 45(3): 274–282. Dostupné z DOI: <http://dx.doi.org/10.1093/rheumatology/kei140>.
  26. Janssens HJ, Janssen M, van de Lisdonk EH et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet 2008; 371(9627): 1854–1860. Dostupné z DOI: <http://dx.doi.org/10.1016/S0140–6736(08)60799–0>.
  27. Iacobuzio-Donahue CA, Lee EL, Abraham SC et al. Colchicine toxicity. Distinct morphologic findings in gastrointestinal biopsies. Am J Surg Path 2001; 25(8): 1067–1073.
  28. Keenan RT, O’Brien WR, Lee KH et al. Prevalence of Contraindications and Prescription of Pharmacologic Therapies for Gout. Am J Med 2011; 124(2): 155–163. Dostupné z DOI: <http://dx.doi.org/10.1016/j.amjmed.2010.09.012>.
  29. Zhang W, Doherty M, Pascual E et al. EULAR evidence based recommendations for gout. Part I. Diagnosis: Report of task force of the ESCISIT. Ann Rheum Dis 2006; 65(10): 1301–1311. Dostupné z DOI: <http://dx.doi.org/10.1136/ard.2006.055251>.
  30. Fernandez C, Noguera R, Gonzales JA et al. Treatment of acute attacks of gout with a small dose of intraarticular triamcinolon acetonide. J Rheumatol 1999; 26(10): 2285–2286.
  31. Kiltz U, Smolen J, Bardin T et al. Treat to target (T2T) recommendations for gout. Ann Rheum Dis 2017; 76(4): 632–638. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2016–209467>.
  32. Emmerson BT. The management of gout. N Engl J Med 1996; 334(47): 445–451.
  33. Becker MA, MacDonald PA, Hunt BJ et al. Determinants of the clinical outcomes of gout during the first year of urate-lowering therapy. Nucleosides Nucleotides Nucleic Acids 2008; 27(6): 585–591.Dostupné z DOI: <http://dx.doi.org/10.1080/15257770802136032>.
  34. Hollingworth P, Reardon JA, Scott JT. Acute gout during hypouricaemic therapy: prophylaxis with colchicine. Ann Rheum Dis 1980; 39(5): 529.
  35. Wortmann RL, Macdonald PA, Hunt B et al. Effect of prophylaxis on gout fl ares after the initiation of urate-lowering therapy: analysis of data from three phase III trials. Clin Ther 2010; 32(14): 2386–2397. Dostupné z DOI: <http://dx.doi.org/10.1016/j.clinthera.2011.01.008>.
  36. Schlesinger N, Mysler E, Lin HY et al. Canakinumab reduces the risk of acute gouty arthritis flares during initiation of allopurinol treatment: results of a double-blind, randomised study. Ann Rheum Dis 2011; 70(7): 1264–1271.Dostupné z DOI: <http://dx.doi.org/10.1136/ard.2010.144063>.
  37. Perez-Ruiz F, Lioté F. Lowering serum uric acid levels: what is the optimal target for improving clinical outcomes in gout? Arthritis Rheum 2007; 57(7): 1324–1328. Dostupné z DOI: <http://dx.doi.org/10.1002/art.23007>.
  38. Chamorro A, Amaro S, Castellanos M et al. Safety and efficacy of uric acid in patients with acute stroke (URICO-ICTUS): a randomised, double-blind phase 2b/3 trial. Lancet Neurol 2014; 13(5): 453–460. Dostupné z DOI: <http://dx.doi.org/10.1016/S1474–4422(14)70054–7>.
  39. Peng F, Zhang B, Zhong X et al. Serum uric acid levels of patients with multiple sclerosis and other neurological diseases. Mult Scler 2008; 14(2): 188–196. Dostupné z DOI: <http://dx.doi.org/10.1177/1352458507082143>.
  40. Schretlen DJ, Inscore AB, Vannorsdall TD et al. Serum uric acid and brain ischemia in normal elderly adults. Neurology 2007; 69(14): 1418–1423. Dostupné z DOI: <http://dx.doi.org/10.1212/01.wnl.0000277468.10236.f1>.
  41. Perez-Ruiz F, Herrero-Beites AM, Carmona L. A two-stage approach to the treatment of hyperuricemia in gout: the “dirty dish” hypothesis. Arthritis Rheu 2011; 63(12): 4002–4006. Dostupné z DOI: <http://dx.doi.org/10.1002/art.30649>.
  42. Scott JT, Higgens CS. Diuretic induced gout: a multifactorial condition. Ann Rheum Dis 1992; 51(2): 259–261.19.
  43. Williams PT. Effects of diet, physical activity and performance, and body weight on incident gout in ostensibly healthy, vigorously active men. Am J Clin Nutr 2008; 87(5): 1480–1487.Dostupné z DOI: <http://dx.doi.org/10.1093/ajcn/87.5.1480>.
  44. Dalbeth N, Chen P, White M et al. Impact of bariatric surgery on serum urate targets in people with morbid obesity and diabetes: a prospective longitudinal study. Ann Rheum Dis 2014; 73(5): 797–802. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2013–203970>.
  45. Richette P, Poitou C, Manivet P et al. Weight loss, xanthine oxidase and serum urate levels: a prospective, longitudinal study of obese patients. Arthritis Care Res (Hoboken) 2016; 68(7): 1036–1042. Dostupné z DOI: <http://dx.doi.org/10.1002/acr.22798>.
  46. Chen JH, Wen CP, Wu SB et al. Attenuating the mortality risk of high serum uric acid: the role of physical activity underused. Ann Rheum Dis 2015; 74(11): 2034–2042. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2014–205312>.
  47. Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ 2008; 336(7639): 309–312. Dostupné z DOI: <http://dx.doi.org/10.1136/bmj.39449.819271.BE>.
  48. Roddy E, Choi HK. Epidemiology of gout. Rheum Dis Clin North Am 2014; 40(2): 155–175. Dostupné z DOI: <http://dx.doi.org/10.1016/j.rdc.2014.01.001>.
  49. Zgaga L, Theodoratou E, Kyle J et al. The association of dietary intake of purine-rich vegetables, sugar-sweetened beverages and dairy with plasma urate, in a cross-sectional study. PLoS ONE 2012; 7(6): e38123. Dostupné z DOI: <http://dx.doi.org/10.1371/journal.pone.0038123>.
  50. Dalbeth N, Wong S, Gamble GD et al. Acute effect of milk on serum urate concentrations: a randomised controlled crossover trial. Ann Rheum Dis 2010; 69(9): 1677–1682. Dostupné z DOI: <http://dx.doi.org/10.1136/ard.2009.124230>.
  51. Dalbeth N, Ames R, Gamble GD et al. Effects of skim milk powder enriched with glycomacropeptide and G600 milk fat extract on frequency of gout flares: a proof-of-concept randomised controlled trial. Ann Rheum Dis 2012; 71(6): 929–934. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2011–200156>.
  52. Choi HK, Curhan G. Coffee, tea, and caffeine consumption and serum uric acid level: the third national health and nutrition examination survey. Arthritis Rheum 2007; 57(5): 816–821. Dostupné z DOI: <http://dx.doi.org/10.1002/art.22762>.
  53. Choi HK, Curhan G. Coffee consumption and risk of incident gout in women: the Nurses’ Health Study. Am J Clin Nutr 2010; 92(4): 922–927. Dostupné z DOI: <http://dx.doi.org/10.3945/ajcn.2010.29565>.
  54. Choi HK, Willett W, Curhan G. Coffee consumption and risk of incident gout in men: a prospective study. Arthritis Rheum 2007; 56(6): 2049–2055. Dostupné z DOI: <http://dx.doi.org/10.1002/art.22712>.
  55. Zhang Y, Neogi T, Chen C et al. Cherry consumption and decreased risk of recurrent gout attacks. Arthritis Rheum 2012; 64(12): 4004–4011. Dostupné z DOI: <http://dx.doi.org/10.1002/art.34677>.
  56. Emmerson BT. The management of gout. N Engl J Med. 1996; 334(7): 445–451. Dostupné z DOI: <http://dx.doi.org/10.1056/NEJM199602153340707>.
  57. Stamp LK, Taylor WJ, Jones PB et al. Starting dose is a risk factor for allopurinol hypersensitivity syndrome: a proposed safe starting dose of allopurinol. Arthritis Rheum 2012; 64(8): 2529–2536. Dostupné z DOI: <http://dx.doi.org/10.1002/art.34488>.
  58. Reinders MK, van Roon EN, Jansen TL et al. Efficacy and tolerability of urate-lowering drugs in gout: a randomised controlled trial of benzbromarone versus probenecid after failure of allopurinol. Ann Rheum Dis 2009; 68(1): 51–56. Dostupné z DOI: <http://dx.doi.org/10.1136/ard.2007.083071>.
  59. Reinders MK, Haagsma C, Jansen TL et al. A randomised controlled trial on the efficacy and tolerability with dose escalation of allopurinol 300–600 mg/day versus benzbromarone 100–200 mg/day in patients with gout. Ann Rheum Dis 2009; 68(6): 892–897. Dostupné z DOI: <http://dx.doi.org/10.1136/ard.2008.091462>.
  60. Halevy S, Ghislain PD, Mockenhaupt M et al. Allopurinol is the most common cause of Stevens-Johnson syndrome and toxic epidermal necrolysis in Europe and Israel. J Am Acad Dermatol 2008; 58(1): 25–32. Dostupné z DOI: <http://dx.doi.org/10.1016/j.jaad.2007.08.036>.
  61. Kim SC, Newcomb C, Margolis D et al. Severe cutaneous reactions requiring hospitalization in allopurinol initiators: a population-based cohort study. Arthritis Care Res (Hoboken) 2013; 65(4): 578–584. Dostupné z DOI: <http://dx.doi.org/10.1002/acr.21817>.
  62. Ramasamy SN, Korb-Wells CS, Kannangara DR et al. Allopurinol hypersensitivity: a systematic review of all published cases, 1950–2012. Drug Saf 2013; 36(10): 953–980. Dostupné z DOI: <http://dx.doi.org/10.1007/s40264–013–0084–0>.
  63. Chung WH, Chang WC, Stocker SL et al. Insights into the poor prognosis of allopurinol-induced severe cutaneous adverse reactions: the impact of renal insufficiency, high plasma levels of oxypurinol and granulysin. Ann Rheum Dis 2015; 74(12): 2157–2164. Dostupné z DOI: <http://dx.doi.org/10.1136/annrheumdis-2014–205577>.
  64. Chao J, Terkeltaub R. A critical reappraisal of allopurinol dosing, safety, and efficacy for hyperuricemia in gout. Curr Rheumatol Rep 2009; 11(2): 135–140.
  65. Reinders MK, van Roon EN, Jansen TL et al. Efficacy and tolerability of urate-lowering drugs in gout: a randomised controlled trial of benzbromarone versus probenecid after failure of allopurinol. Ann Rheum Dis 2009;68(1):51–56. Dostupné z DOI: <http://dx.doi.org/10.1136/ard.2007.083071>.
  66. Pui K, Gow PJ, Dalbeth N. Efficacy and tolerability of probenecid as urate-lowering therapy in gout; clinical experience in high-prevalence population. J Rheumatol 2013; 40(6) :872–876. Dostupné z DOI: <http://dx.doi.org/10.3899/jrheum.121301>.
  67. Perez-Ruiz F, Calabozo M, Pijoan JI et al. Effect of urate-lowering therapy on the velocity of size reduction of tophi in chronic gout. Arthritis Rheum 2002; 47(4): 356–360. Dostupné z DOI: <http://dx.doi.org/10.1002/art.10511>.
  68. Pavelka K. Nové pohledy na léčbu hyperurikémie a dny. Interni Med Praxi 2008; 10(6): 268–272.
  69. Taylor TH, Mecchella JN, Larson RJ et al. Initiation of allopurinol at first medical contact for acute attacks of gout: a randomized clinical trial. Am J Med 2012; 125(11): 1126–1134.e7. Dostupné z DOI: <http://dx.doi.org/10.1016/j.amjmed.2012.05.025>.
Diabetology Endocrinology Internal medicine
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account