What lies ahead?

Clearly, much can still be accomplished toward improving the long-term management of hyperuricemia with currently available forms of ULT. Adherence to treatment and greater educational efforts directed at both patients and clinicians would go a long way toward preventing the morbidity associated with gout. But even under the very best of conditions, an estimated 100,000-300,000 of the nearly 5 million U.S. patients with gout would not be adequately managed by current therapies.15 These patients are the target population for new and innovative ways to lower serum uric acid.

While the majority of gout patients do not achieve adequate control of their hyperuricemia or symptoms, they are not truly treatment failures. These patients are generally victims of inadequate prescribing, poor compliance, or both. The term “treatment-failure gout” should be reserved for those symptomatic patients with contraindications to the currently available urate-lowering medications or when the maximum medically appropriate dose of those agents does not control hyperuricemia.

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Two new urate-lowering medications are very close to gaining FDA approval (the first ones since the release of allopurinol more than 40 years ago). Pegloticase offers the promise of urate lowering through a mechanism totally different from the excretion-enhancing probenecid or the synthesis-blocking medications allopurinol and the soon-to-be-released febuxostat.

Finally, enhanced educational efforts directed at clinicians ought to emphasize:

1. Prompt and aggressive treatment of acute gout
2. An accepted target for urate lowering (serum uric acid level <6.0 mg/dL) to prevent gout and perhaps a lower goal in certain comorbidities
3. Recognition that allopurinol dosing >300 mg/day is often required to achieve this goal. The widely published guidelines restricting the maximum dose of allopurinol in patients with chronic kidney disease is not warranted and will not be sufficient in many cases.
4. The involvement of patients in lifestyle changes (e.g., dietary restriction of purine-rich food and drink, limiting fructose intake, and the control of metabolic syndrome) is essential to stem this epidemic. The Gout & Uric Acid Education Society has a reliable and noncommercial Web site created by experts in the field to educate patients and professionals about gout and hyperuricemia (www.gouteducation.org).

As these tenets become better recognized by providers and the general public and as new therapies are developed, gout treatment may finally emerge from the dark ages.

Ms. McTigue is a physician assistant in the Division of Rheumatology at the University of Florida College of Medicine and the Veterans Affairs Medical Center in Gainesville.

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All electronic documents accessed October 7, 2008.