Current Concepts In Managing Chronic Gout
When Patients Have Refractory Chronic Gout
Refractory chronic gout occurs in patients who have failed to normalize serum uric acid and whose signs and symptoms are not adequately controlled with xanthine oxidase inhibitors. Patients with chronic refractory gout often present to our offices with large tophi with or without ulceration. Historically, these patients have had surgical excision of the tophi. However, patients with refractory chronic gout most often present with a high comorbidity burden, adding significant risk to any planned surgical intervention. There are also the significant complications that can occur after the tophi excision itself.
What if one could resolve tophi without surgery? A new medication, pegloticase (Krystexxa, Savient Pharmaceuticals), now offers hope for these patients with refractory chronic gout. Pegloticase catalyzes the breakdown of uric acid into allantoin, which the kidneys easily excrete. Pegloticase has the power to decrease serum uric acid to near undetectable levels.13 As I discussed above, this creates a strong gradient that acts as a powerful debulking agent. Therefore, pegloticase can significantly and quickly reduce the total body urate pool.
Pegloticase is exciting for its potential to resolve tophi. In clinical trials, there was 100 percent resolution of at least one tophi in 45 percent of patients.13 These results can be quite rapid and dramatic. Although no medication is without risk, surgery in this patient population is not exactly risk-free either. Pegloticase offers the prospect of preventing surgery and resolving tophi pharmacologically, which is an option we have not had in our armamentarium until relatively recently.
When To Refer Patients For Gout
Everyone is going to have a different level of comfort when treating chronic gout. Some podiatrists may choose only to manage acute gouty flares while others may choose to manage the patient’s urate lowering therapy. Either choice is reasonable as long as someone on the patient’s medical team initiates urate lowering therapy in a timely manner. At the very least, it is the job of every podiatrist to obtain the proper care and consults to help prevent the next acute gouty attacks.
No matter what your level of expertise is, having a good working relationship with a local rheumatologist will become necessary at some point. When should you consider calling on the expertise of a rheumatologist? Here are some clinical scenarios that may warrant a possible consult:
• if there is an unclear etiology of hyperuricemia;
• if there are refractory signs and symptoms of gout;
• if there is difficulty in reaching the target serum urate levels; and/or
• if there have been multiple and/or serious adverse events from urate lowering therapy.
Dr. Neville is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice in Indianapolis.
The author gives special thanks to Herbert Baraf, MD, for the tophi pictures in this article.