Background/Purpose: Gout is a common inflammatory arthritis triggered by deposition of monosodium urate crystals in joints, bone and soft tissues, with a prevalence of 1-4% worldwide. Both incidence and prevalence are rising globally, conferring a large individual and societal burden. Management has traditionally proven difficult, with suboptimal urate monitoring and lack of titration of urate lowering therapy (ULT).

‘Treat to target’ approaches have now been extensively validated in other conditions such as rheumatoid and psoriatic arthritis, with distinct benefit to the patient. In gout, treat to target has been shown to result in reduced flare frequency, reduced tophi and improved quality of life.

Current European League Against Rheumatism and British Society of Rheumatology guidelines recommend control of serum uric acid (SUA) ≤ 0.30 and ≤0.36 mmol/L respectively.The American College of Rheumatology guideline published in 2020 also recommends ULT dose titration guided by serial urate measurements, with a target of < 6mg/dl (< 0.36mmol/L).

This non-blinded, randomised controlled trial compared conventional management with monthly ULT titration on achieving and maintaining SUA at the target level of ≤0.30mmol/L.

Methods: 110 patients aged 18-85 were prospectively recruited and randomly allocated to two cohorts. The conventional treatment cohort were reviewed at 0, 6 and 12 months with ongoing care via family physician. The tight control cohort were reviewed at monthly intervals for 12 months.

All study patients were commenced on Allopurinol 100mg daily plus anti-inflammatory/colchicine or steroid, as flare prophylaxis. Any patient with a contraindication to Allopurinol was prescribed Feboxustat 80mg daily. Both groups of patients were educated and advised to have urate monitoring and dose escalation until target SUA of 0.30mmol/l was achieved. Ultrasound assessment of greyscale synovitis, erosion and tophus was compared at month 0 and 12.

Results: 89.4% of patients in the tight control arm achieved target urate of ≤0.30, compared to only 39.6% in the conventional treatment group (p-value < 0.001). This reflects a change in SUA at 6 months of 37.6% and 18.0% in the tight and conventional groups respectively (confidence interval 12.4-26.9).

Reduction in ultrasound features of gout at the knee (greyscale synovitis) was demonstrated, with improvement observed in 63% of the tight control group compared to 14% of the conventional group (p-value 0.043, confidence interval 0.01-0.97). Reduction in tophus size at the first MTP joint was significantly different between the 2 groups; with a median reduction of -4.65mm in the tight control group compared to only -0.30mm in the conventional arm (p-value 0.003). There was also a difference in the presence/absence of double contour sign at the first MTP between the 2 groups at the final visit: 62.5% patients in the conventional group still had double contour present, compared to only 40% of those in the tight control group, although these numbers were small and did not achieve statistical significance.

Conclusion: This study has demonstrated that tight control of gout leads to highly statistically significant improvements in SUA and resolution/ improvement of ultrasound features of gout.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-ticog-study-tight-control-of-gout-a-randomized-controlled-trial-of-targeted-versus-conventional-treatment-for-gout-including-ultrasonography/