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Between the Lines: New Treatment Paradigms in Gout - Episode 4

Challenges With Gout Treatment

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Orrin M. Troum, MD, and Jeff R. Peterson, MD, discuss challenges with gout treatment.

Orrin M. Troum, MD: That brings us to our discussion questions. The MIRROR RCT study was important in bringing this to the population that utilizes this medication. When we talk about the approach of treating patients with chronic gout, there are some challenges to treatment. What might those challenges be, Jeff? What challenges do we encounter?

Jeff R. Peterson, MD: The first thing that’s so important about patients with gout is that they’re terribly inconsistent with follow-ups and taking their medications. I try to impose on them the knowledge that gout is a chronic disease; it doesn’t go away. Just because you’re not having a flare doesn’t mean it’s not there. Many of my patients stop taking their allopurinol because they’re not having a flare. Then they come back a year later with a horrible flare, and say, “I didn’t fill it because I didn’t think I had gout anymore.” I’m like, “No, you always have gout.” A big problem is making sure those patients are educated and stay on their oral medications, but we already know that many patients don’t.

Having an IV [intravenous] medication that we can give them—and knowing they’re getting the medication—is helpful. We do this with some of our other patients when we don’t trust them to do their home injections with their TNF [tumor necrosis factor] inhibitor or whatever. We give it to them with an IV in the office because we don’t want them to miss their medications. Worse, they could have an illness, take their medication, and get pneumonia and end up in the hospital.

We have those same problems with our patients with gout. You asked me my approach to these patients. Education is my main approach. I always start with oral therapies because those are appropriate. There are rare patients who are not able to achieve my goal of around 4.5 mg/dL or less. I have a few patients who have essentially normal serum uric acid at like 5.9 or 6 mg/dL, but they have big tophi. Even though they have normal serum uric acid, they’re still collecting gout crystals. For those patients, I want to make sure I’m getting them much lower in their serum uric acid levels.

Once I’m done with the oral therapies, if they require Krystexxa [pegloticase], then I discuss with them why I’m using immunomodulation. As you said before, we’re trying to prevent the antibody formation. It shows that the results that have shown very clearly, in the intent-to-treat population, that we’re getting double the efficacy if we use immunomodulation. That’s huge, so this is our last-ditch effort. We want to make sure we’re keeping those patients on a complete course, so we can achieve our goals. If we’re using immunomodulation, they’re not making antibodies, so if we have to use it again in the future, they’re still able to do that. That’s what I’m doing right now with patients.

Orrin M. Troum, MD: That’s coming from an expert, and this is why it may be helpful for those listening to this. In the future, there may be something that you and John [Botson] have thought about—certain places that people will come to or be referred to regarding getting the appropriate treatment for someone who has chronic gout. There are so many people. Three to 4 times as many people have [gout compared with] rheumatoid arthritis. There are over a dozen medications that can control rheumatoid arthritis, but only a few medicines are used to treat gout. Then we have to get them to the appropriate person, the appropriate group, or the appropriate center to help is something that you’ve been talking about. This is going to come to fruition, hopefully in the next year or so with a center of excellence.

Jeff R. Peterson, MD: We’re working on that. Many patients are falling into podiatry clinics or are being seen in nephrology clinics, so educating those physician groups has been helpful in identifying these severe patients. I hope we can get in front of more primary care doctors as well, because 1 of the comorbidities of bad gout is that cardiovascular risk is high. Untreated gout havs the same cardiovascular risk as untreated diabetes. Everyone knows diabetes is bad, but they don’t worry about gout. We need to get that message out there.

Orrin M. Troum, MD: It’s really important.

Transcript edited for clarity