As gout prevalence climbs, new research backs Treat-to-Target strategies for effective management to reduce uric acid levels and mean gout flare rate.
Overview of Gout
Gout, the most common form of inflammatory arthritis, affects millions of individuals worldwide. It is characterised by the excess of uric acid, which forms crystals in the presence of elevated urate concentrations. There are two schools of thought when it comes to gout management strategies. They are Treat-to-Target (T2T) and Treat-for-Symptom Avoidance (T2S) strategies. In a recent meeting on rheumatology, a study presented supports T2T as an evidence-based approach for gout treatment, which may influence future guidelines and non-specialist practice. In this article, we share the findings so that healthcare professionals can play a crucial role in providing optimal patient care for gout patients by understanding the evolving management strategies.
Global Prevalence of Gout: A Growing Concern
The reported prevalence of gout globally varies from 0.1% to approximately 10%, and the incidence ranges from 0.3 to 6 cases per 1,000. In recent years, the prevalence and incidence of gout have shown a concerning upward trend across developed countries. Notably, gout affects more than 1% of the population in most of these nations, with particularly high rates observed in North America and Europe.
Insights into The Rise of Gout in Asian Countries
In Asia, the numbers vary, with South Korea and Japan having the lowest prevalence. Comparing the global prevalence of gout, Taiwan, Hong Kong, and Singapore exhibit higher rates. In Hong Kong, a 2001 survey found that 5.1% of individuals aged 45–59 years and 6.1% of those older than 60 years had gout. Meanwhile, the Singapore Chinese Health Study identified 4.1% of people with gout between 1999 and 2004 among a group of 52,322 individuals aged 45–74 years. In Taiwan, approximately 4.92% of residents were diagnosed with gout in 2004, with Aboriginal populations showing a particularly high prevalence.
Gout Management Matters
Gout is notorious for causing intense joint pain, which impacts physical function, quality of life, and healthcare costs. Additionally, individuals with gout face an elevated risk of various cardiovascular outcomes, including heart failure, arrhythmias, and valve disease. Gout has also recently been linked to dementia. Therefore, timely management can alleviate symptoms and improve patient well-being. For effective gout management, strategies should not only address acute attacks but also implement lifestyle changes and medications to mitigate both joint symptoms and long-term health risks. The importance of conducting formal cardiovascular risk assessments for gout patients is also crucial to reduce future atherosclerotic and cardiorenal risks. Notably, the BMJ published in 2022 a concise and comprehensive National Institute for Health and Care Excellence (NICE) guideline for diagnosis and managing gout.
Emerging Research Validates the Treat-to-Target (T2T) Approach
Elevated serum uric acid level is considered the driver of both flares and the complications of gout. This link has prompted its inclusion in the treatment guidelines recommended by major associations, including the American College of Rheumatology and the European Alliance of Associations for Rheumatology (EULAR). However, other institutions like the American College of Physicians (ACP) continue to support a symptom-based approach. Although widely recommended, the efficacy of the T2T strategy has lacked robust validation until now.
The GO TEST OVERTURE trial, a pivotal multicenter study, compared T2T and T2S strategies. Involving 308 participants across eight centres, the study revealed a significant reduction in gout flare frequency in the T2T group, using standard treatments like allopurinol, benzbromarone, and febuxostat to maintain serum uric acid levels below 0.36 mmol/L. In contrast, the T2S group did not employ serum uric acid levels to guide their treatment choices, resulting in a higher average flare rate. T2T resulted in a mean gout flare rate of 1.3 compared to T2S with a rate of 1.85, and a higher proportion of patients in the T2T group (77% compared to 29% in T2S group) achieved the serum uric acid level target.
Survey Findings: Insights for Healthcare Professionals on Gout Remission
Findings from a survey presented at the recent EULAR conference offered crucial insights into the perceptions of gout remission among healthcare professionals. The survey included 151 rheumatologists, 150 nephrologists, and 102 primary care physicians. A consensus emerged that the absence of flares is a critical criterion for gout remission. However, only a minority of primary care physicians (30%) and nephrologists (35%) recognise the T2T target of less than 0.36 mmol/L as a top criterion, compared to 64% of rheumatologists. On the other hand, a significant percentage of primary care physicians (58%) and nephrologists (42%) prioritise the absence of gout pain over serum uric acid levels. These findings highlight the urgent need for a standardised definition of gout remission that incorporates both the control of serum uric acid levels and symptom management.
Embracing T2T as an Evidence-Based Strategy
As the incidence continues to climb across Asia, it is crucial for healthcare professionals to recognise and implement the most effective treatment strategies. The Treat-to-Target (T2T) approach, now backed by the compelling findings from the GO TEST OVERTURE trial, has proven its efficacy in managing gout more comprehensively than mere symptom relief. Although the study’s results are yet to be published, numerous medical associations have already aligned with the T2T guidelines, recognising its evidence-based benefits. Given this shift, healthcare professionals should prioritise incorporating T2T strategies into their clinical practices, ensuring that patients receive the most advanced care aimed at long-term disease control and quality of life improvement.
References
- Ng, G. (2023, July 19). Understanding Uric Acid & Its Role in the Body. Medical Channel Asia. https://medicalchannelasia.com/understanding-uric-acid-its-role-in-the-body/
- Kuo, C. F., Grainge, M., Zhang, W., et al. (2015). Global epidemiology: Prevalence, incidence and risk factors. Nature Reviews Rheumatology, 11(11), 649–662. https://doi.org/10.1038/nrrheum.2015.91
- Ferguson, L., McInnes, I. B., Sattar, N., & Conrad, N. (2023, November). Gout is associated with increased cardiovascular risk: Results from analysis of the CPRD dataset. European Heart Journal, 44(Supplement_2), ehad655.2771. https://doi.org/10.1093/eurheartj/ehad655.2771
- Yap, A. (2021, December 8). Uncovering The Disease and Living With It. Medical Channel Asia. https://medicalchannelasia.com/gout-uncovering-the-disease-and-living-with-it/
- Neilson, J., Bonnon, A., Dickson, A., & Roddy, E. (2022). Gout: diagnosis and management—summary of NICE guidance. BMJ, 378, o1754. https://doi.org/10.1136/bmj.o1754
- Moses, A., Oude Voshaar, M., Jansen, T., et al. (2024). OP0116 Treat to Target in Gout Yields Superior Outcomes Compared to Treat to Avoid Symptoms Approach (Results From Gout Treatment Strategy (GO TEST) Overture Trial). Annals of the Rheumatic Diseases, 83(Suppl 1), 86. https://ard.bmj.com/content/83/Suppl_1/86.1
- Klionsky, Y., Luo, E., Vazquez Irizarry, S., et al. (2024). POS0269 emission as viewed by rheumatologists, nephrologists, and primary care physicians. Annals of the Rheumatic Diseases, 83(Suppl 1), 409-410. https://ard.bmj.com/content/83/Suppl_1/409.1
