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Management of Acute and Recurrent Gout

TO THE EDITOR: We note with interest Qaseem and colleagues' clinical practice guideline for management of gout (1). Given the prevalence of this condition, its substantial disease burden, and the availability of potentially curative therapies, skillful and purposeful management by primary care physicians and rheumatologists is imperative. In light of existing clinical practice guidelines by the American College of Rheumatology (2) and the European League Against Rheumatism (3) recommending a treat-to-target approach for long-term urate-lowering therapy, seeing a new guideline from the American College of Physicians that suggests an alternative treat-to-avoid-symptoms paradigm is surprising. The prospect of administering urate-lowering therapy without monitoring serum urate levels may be alluring. However, doing so would be a step backward given our current understanding of gout pathophysiology, because hyperuricemia seems to be directly responsible for causing gout (4). Most patients with gout can achieve disease remission with an aggressive treat-to-target approach; whether an alternative approach would be equally effective remains unclear. Benefits of monitoring serum urate levels during therapy include the potential for dose adjustment based on variabilities in individual response to medication, verifying medication adherence, and the ability to prevent future flares by targeting a specific serum urate goal. Implicit in the treat-to-avoid-symptoms approach is the assumption that alleviating symptoms is the primary reason for using urate-lowering therapy. We suggest that current symptoms provide only part of the impetus for gout therapy and that other clinical features may be just as compelling. For example, gouty erosions on radiography or a history of tophaceous disease of any kind should be sufficient reason for aggressive treatment of hyperuricemia regardless of current symptoms. Furthermore, although dramatic symptoms are typical of early gout, chronic gouty arthritis can at times be relatively asymptomatic during intercritical periods even while joint inflammation (as shown by ultrasonography) is ongoing (5). Thus, symptom-based therapy alone is inadequate and could cause increased chronic morbidity because of less aggressive treatment. We agree that future gout research should focus on better establishing optimal serum urate-lowering goals and consider the benefits of a symptom-based treatment paradigm, but we believe that suggesting treating to avoid symptoms is premature at this time.