Chasing crystals out of the body: will treat to serum urate target for gout help us get there?

In this issue of the journal, Kiltz et al published the treat-to-target (T2T) recommendations for gout, based on a systematic literature review (SLR) using standard methodology based on Oxford Center for Evidence-based Medicine system and the AGREE criteria. 3 The expert group developed nine T2T recommendations for gout management. Key T2T recommendations were that serum urate (sUA) should be lowered and maintained at <6 mg/dL (<360 mmol/L) in all patients with gout (high-level evidence) and at <5 mg/dL (<300 mmol/L) in those with severe gout (including tophi or frequent attacks; expert opinion). Inherent to achieving target sUA was the recommendation that sUA should be measured regularly in patients with gout (moderate-level evidence), so that uratelowering therapy (ULT) dose adjustment can be guided by the sUA level. An updated literature review of T2T strategies in gout identified is a lack of randomised trials that have tested the T2T strategy for gout versus other approaches. The panel also agreed that an appropriate strategic approach to treatment of asymptomatic hyperuricaemia needs to be developed, but lack of evidence prevented the group from making a recommendation regarding a treatment target different than the one recommended for gout. These recommendations and gout treatment guidelines already support a T2T tactic in gout with a goal of sUA target of <6 mg/dL (<360 mmol/L) in all patients with gout and <5 mg/dL (<300 mmol/L) in patients with tophaceous or severe gout. Thus, the T2T recommendations for gout in this article1 are consistent with the previous recommendations/guidelines for the treatment of gout. Although consisting primarily of rheumatologists, the group ought to be congratulated for putting together a multistakeholder team including an internist, nephrologist, cardiologist and a patient. Inclusion of various stakeholders, and not only gout researchers, allows for a richer discussion that goes beyond only one point of view or belief. This inclusive and thoughtful approach also improves the likelihood that this guidance will be taken seriously by practitioners other than rheumatologists. Some differences in the perceptions related to ULT dosing and target sUA achievement have been noted by patient and physician characteristics. 8 Previous research has suggested that use of antiinflammatory prophylaxis at the initiation of ULT (to prevent acute gout flares) is more common if the provider of gout care is a rheumatologist versus a nonrheumatologist. Studies of current practice also show that the achievement of target sUA, a key gout outcome, occurs in a low proportion of patients with gout, ranging from 20% to 33% to 44% in various studies. This is primarily due to the lack of knowledge among providers and patients regarding the importance of ULT dosing and achievement of target sUA. Is the patient more likely to achieve target sUA if the provider of gout care is a rheumatologist? This is an important question to answer since the majority of patients with gout in the USA and worldwide are managed by nonrheumatologists (primary care physicians and other specialists). If a difference exists by provider specialty, new programmes and care paradigms could be designed to improve access to specialty care, train primary care physicians regarding the appropriate use of ULT or have nurseor pharmacist-led programmes. A recent UK study has shown that a nurse-led programme in a rheumatology clinic consisting of education, individualised lifestyle advice and appropriate ULT helped >90% patients with gout from primary care practices to achieve target sUA <6 mg/dL during a 12-month follow-up. Another randomised trial in California showed that the success rate of target sUA at 26 weeks was significantly higher in patients who received information by phone through a pharmacist versus usual care. Thus, care by a specialist and/or targeted programmes that include patient education or intensive frequent monitoring can improve our ability to achieve target sUA in gout. A T2T approach for any chronic disease could be challenging. Despite many years of educational efforts, clinicians continue to manage gout suboptimally. A comprehensive strategy with regular monitoring for sUA level, adverse events, pain and quality of life of patients may be essential for a successful T2Tapproach in patients with gout.