Background/Purpose:

Gout is frequent and severe in Vietnam, where urate-lowering drugs (ULD) are seldom used and many patients are treated only with traditional herbal medicine. We looked at the effect of a Treat to Target strategy (T2T) using allopurinol on severe Vietnamese gout.

Methods: One hundred Vietnamese, ULD- free, crystal-proven gout patients (99 men,1 woman) with a GFR > 60 ml/min, were prospectively followed during an aimed period of 12 months (M) after allopurinol (ALLO) initiation. The median age of patients was 47 years (y), median disease duration 10 y, median BMI 25 kg/m², 91 patients had multiple palpable tophi, 32 had hypertension, 7 type 2 diabetes, 31 dyslipidemia, 47 coronary heart disease, 16 were on long term steroid. Treatment protocol included full patient information, titration of ALLO up to reaching a predefined SUA target (6 mg/dL in 5 patients and 5 mg/dL in 95), flare prophylaxis by colchicine (0.5 to 1mg/d) during the first months, and traditional herbal medicine. At each visit, gout flares from the last visit were counted using a daily diary, palpable tophus size was assessed using a Vernier caliper, SUA was measured. Ultrasound (US) scan was performed at inclusion and every 3 M and allowed search for double contour (DC) sign at the knees and first MTP joints -which were found in all patients at baseline and classified into 4 classes (thick, medium, thin and none)- and measurement of a hand or foot index tophus. Quality of life (gout impact scale (GIS) and function were recorded at inclusion and after 12 M. The effect of SUA lowering was explored by comparing inclusion and 12-M data, in patients who reached their SUA target and those who did not, using standard statistics.

Results:

Eighty four and 68 patients were seen at M6 and M12, respectively. Reasons for loss of follow-up were major improvement (12), alcoholism (2), long distance from the center (8), inter-current disease or personal problem (9), and intolerance to ALLO (4). The mean maximal dose of ALLO was 520 (+165) mg/d and was reached after a median of 2 (+1.3) M. SUA target was obtained in 89 patients. Mean flare rate per M significantly declined from 2.5 on M1 (n=98) to 1.1 at M6 (n=84) (p<0.001), and 0.15 at M12 (n=68) (p<0.001), at a time when all patients were free of prophylactic colchicine, NSAIDs or steroid but remained under herbal treatment, with no significant inflence of SUA. GIS significantly similarly strongly improved in all dimensions (p<0.02) except for fear of side effects (p=0.13) and did not significantly correlate with SUA target. Function significantly (p<0.004) improved, and even more in patients at target (p<0.001). Tophi (p<0.001 for both caliper and US measurements) and DC sign (p<0.03 for all locations) significantly decreased between inclusion and M12 and both decreases correlated with achievement of SUA target (p=0.004 for tophi, and <0.03 for DC disappearance).

Conclusion: The T2T strategy strikingly improved patients. Tophi and DCs decreased, and function improved in correlation with achievement of SUA target. Flare rate dramatically decreased and GIS strongly improved but these changes did not correlate with SUA, suggesting a lack of statistical power or an anti-inflammatory effect of high dose ALLO and/ or herbal medicine.

« Back to 2017 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/urate-lowering-to-acr-recommended-targets-allows-significant-improvement-of-severe-gout-a-monocentric-prospective-trial-in-vietnam-using-a-systematic-treatment-protocol/