Treatment Checklist
Some factors to keep in mind when considering long-term treatment for your gout patients:
- Reducing serum urate levels is important. The treatment target for chronic antihyperuricemic therapy is reduction of serum urate concentration to < 6.0 mg/dL (0.36 mmol/L)—below the threshold for extracellular fluid precipitation of monosodium urate crystals. This level has been shown to help reduce the risk of recurrent attacks and disease progression.
- Positive changes. Consider recommending lifestyle modifications such as gradual weight loss and a reduction of alcohol consumption as appropriate. Dietary modifications may be appropriate for patients who eat large amounts of purine-rich foods. However, in most cases ingestion of purines plays a relatively small role in hyperuricemia, and traditional "low-purine" diets generally result in less than a 1 mg/dL decrease in serum urate levels.
- Monitoring sUA levels. Establish sUA level in the absence of acute flare and monitor periodically thereafter to guide the long-term management of the disease.
- Starting therapy. Patients should know that initiation of urate-lowering therapy may precipitate a gout flare (mobilization flare), due to changes in the serum urate concentration. Consider the use of prophylactic drugs for 6 months or longer to help prevent this.
- Committing to treatment. Patients must understand that antihyperuricemic therapy requires a lifelong commitment and that they must be prepared to continue therapy even if a flare occurs during treatment. Make sure your patients know that any sudden change in uric acid level—even lowering uric acid—can cause attacks. Such flares may be a sign that the medication is working effectively.
- Staying consistent. Patient compliance is important to successful gout therapy. Inconsistent use of medication may precipitate additional acute gout attacks in response to fluctuations of the serum urate level. Withdrawal of urate-lowering therapy may have the same effect.
- Increasing compliance. Keep in mind some of the factors found to be associated with compliance:
- Fear of forgetting to take the gout medication
- Desire to continue functioning well
- Having a consistent routine (eg, medication stored in the same place)
- Impact of the side effects of acute gout treatment
- Questions to ask yourself and your patient. Consider how you might address such issues with your patients: Consider the following:
- Do they understand the commitment they are making to chronic treatment and the consequences of not following through on a consistent basis?
- Do they understand the short- and long-term effects of chronic hyperuricemia in gout on their ability to function and their health-related quality of life?
- Are they equipped with a system to remember their gout medication schedule? Can you address the multiple medications and varying schedules they may have?
- Have you reviewed the possibility of a mobilization flare, what can be done to help prevent it, and why this type of flare may be a sign that their medication is working to lower their uric acid?