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To investigate whether multi-joint ultrasound (US) findings in patients with gouty arthritis could be used to distinguish between acute and chronic stages, we performed a retrospective study with 129 enrolled patients from the Rheumatology Department of the First Affiliated Hospital of Chengdu Medical College from September 1, 2018 to June 12, 2019. Patients with acute or non-acute gout were categorized using clinical data, and US imaging findings of the knees, ankles and first metatarsophalangeal joints were analyzed and compared between groups. Notably, we found that the most prevalent sign detected by US was the hyperechoic spot in the synovium, followed by arthrosynovitis, aggregates, double contour signs and tophi; meanwhile, bone erosions were the least common. Additionally, synovitis was more frequently detected in the acute joints of gouty arthritis (49%) compared with the non-acute joints (35%), whereas grade 1 or 2 blood flow classifications (97%), tophi and bone lesions were more often seen in the latter. Overall, our data suggest that multi-joint US scanning might be used to evaluate disease severity and discriminate between stages of gouty arthritis.

A scoping review that will synthesise clinical definitions of chronic refractory gout and identify treatment pathways for this condition.

Objective Disagreement exists between rheumatology and primary care societies regarding gout management. This paper describes a formal process for gathering input from stakeholders in the planning of a trial to compare gout management strategies. Methods We recruited patients, nurses, physician assistants, primary care clinicians, and rheumatologists to participate in a modified Delphi panel (mDP) to provide input on design of a trial focused on optimal management for primary care patients with gout. The 16 panelists received a plain-language briefing document that discussed the rationale for the trial, key clinical issues in gout, and aspects of trial design. The panelists also received information and considerations on nine voting questions (VQs), judged to be the key design questions. Cognitive interviews with panelists ensured that the VQs were understood by the range of panelists involved in the mDP. Panelists were asked to score all VQs from 1 (definitely no) to 9 (definitely yes). Two voting rounds were conducted-round 1 by email and round 2 by video conference. Results The VQs were modified through the cognitive interviews. The round 1 voting resulted in consensus on eight items, with consensus defined as median voting score in the same tercile (1-3, 4-6 or 7-9). Re-voting at the meeting (round 2) reached consensus on the remaining item. Conclusion An mDP with various stakeholders facilitated consensus on the design of a trial of different management strategies for chronic gout. This method may be useful for designing trials of clinical questions with substantial disagreement across stakeholders.

The initial presentation of gouty arthritis can be a dramatic event. Chronic gout may lead to the destruction of joints, invalidity and increased mortality. The incidence of this disorder is high, despite effective therapeutic measures. The treatment of refractory cases may be a challenge to the general practitioner and the specialist alike. The article presented here summarizes the current state of diagnostics and treatment of acute and chronic gout.

Hyperuricemia and chronic deposition of monosodium urate crystals are the main cause of the gout. Urate lowering therapy (ULT) is the mainstay of chronic gout treatment. In this study, we evaluated demographic features and disease properties of the patients that would relate with the success of ULT. Sixty-six gout patients on pharmacologic ULT were enrolled in the study. Non-adherence to pharmacologic ULT was an exclusion criterium. Demographic and therapeutic features and co-illnesses and disease features of the patients were obtained during the study. Then, we compared these parameters between the patients with successful ULT and inadequate ULT. Adherence to diet was found different between the groups (OR, 7.00; CL%95 2.27 - 21.56). All other features including maximum allopurinol dosage were similar. We found that diet was the only factor that relate with success of ULT, while patients were on pharmacologic ULT. Non-adherence to both pharmacologic and non-pharmacologic measures is the main problem during ULT. Therefore, clinicians should emphasize the importance of all segments of ULT, including diet with informing patients during visits about the nature of disease and benefits of ULT.

Background Dietary supplements are frequently used for the treatment of several medical conditions, both prescribed by physicians or self administered. However, evidence of benefit and safety of these supplements is usually limited or absent. Objectives To assess the efficacy and safety of dietary supplementation for people with chronic gout. Search methods We performed a search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL on 6 June 2013. We applied no date or language restrictions. In addition, we performed a handsearch of the abstracts from the 2010 to 2013 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) conferences, checked the references of all included studies and trial registries. Selection criteria We considered all published randomised controlled trials (RCTs) or quasi-RCTs that compared dietary supplements with no supplements, placebo, another supplement or pharmacological agents for adults with chronic gout for inclusion. Dietary supplements included, but were not limited to, amino acids, antioxidants, essential minerals, polyunsaturated fatty acids, prebiotic agents, probiotic agents and vitamins. The main outcomes were reduction in frequency of gouty attacks and trial participant withdrawal due to adverse events. We also considered pain reduction, health-related quality of life, serum uric acid (sUA) normalisation, function (i.e. activity limitation), tophus regression and the rate of serious adverse events. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Main results We identified two RCTs (160 participants) that fulfilled our inclusion criteria. As these two trials evaluated different diet supplements (enriched skim milk powder (SMP) and vitamin C) with different outcomes (gout flare prevention for enriched SMP and sUA reduction for vitamin C), we reported the results separately. One trial including 120 participants, at moderate risk of bias, compared SMP enriched with glycomacropeptides (GMP) with unenriched SMP and with lactose over three months. Participants were predominantly men aged in their 50's who had severe gout. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the study period. The effects of enriched SMP (SMP/GMP/G600) compared with the combined control groups (SMP and lactose powder) at three months in terms of mean number of gout flares per month were uncertain (mean ± standard deviation (SD) flares per month: 0.49 ± 1.52 in SMP/GMP/G60 group versus 0.70 ± 1.28 in control groups; mean difference (MD) -0.21, 95% confidence interval (CI) -0.76 to 0.34; low-quality evidence). The number of withdrawals due to adverse effects was similar in both groups although again the results were imprecise (7/40 in SMP/GMP/G600 group versus 11/80 in control groups; risk ratio (RR) 1.27, 95% CI 0.53 to 3.03; low-quality evidence). The findings for adverse events were also uncertain (2/40 in SMP/GMP/G600 group versus 3/80 in control groups; RR 1.33, 95% CI 0.23 to 7.66; low-quality evidence). Gastrointestinal events were the most commonly reported adverse effects. Pain from self reported gout flares (measured on a 10-point Likert scale) improved slightly more in the SMP/GMP/G600 group compared with controls (mean ± SD reduction -1.97 ± 2.28 points in SMP/GMP/G600 group versus -0.94 ± 2.25 in control groups; MD -1.03, 95% CI -1.96 to -0.10; low-quality evidence). This was an absolute reduction of 10% (95% CI 20% to 1% reduction), which may not be of clinical relevance. Results were imprecise for the outcome improvement in physical function (mean ± SD Health Assessment Questionnaire (HAQ)-II (scale 0 to 3, 0 = no disability): 0.08 ± 0.23 in SMP/GMP/G60 group versus 0.11 ± 0.31 in control groups; MD -0.03, 95% CI -0.14 to 0.08; low-quality evidence). Similarly, results for sUA reduction were imprecise (mean ± SD reduction: -0.025 ± 0.067 mmol/L in SMP/GMP/G60 group versus -0.010 ± 0.069 in control groups; MD -0.01, 95% CI -0.04 to 0.01; low-quality evidence). The study did not report tophus regression and health-related quality of life impact. One trial including 40 participants, at moderate to high risk of bias, compared vitamin C alone with allopurinol and with allopurinol plus vitamin C in a three-arm trial. We only compared vitamin C with allopurinol in this review. Participants were predominantly middle-aged men, and their severity of gout was representative of gout in general. The effect of vitamin C on the rate of gout attacks was not assessed. Vitamin C did not lower sUA as much as allopurinol (-0.014 mmol/L in vitamin C group versus -0.118 mmol/L in allopurinol group; MD 0.10, 95% CI 0.06 to 0.15; low-quality evidence). The study did not assess tophus regression, pain reduction or disability or health-related quality of life impact. The study reported no adverse events and no participant withdrawal due to adverse events. Authors' conclusions While dietary supplements may be widely used for gout, this review has shown a paucity of high-quality evidence assessing dietary supplementation.

Gout is the most common inflammatory arthropathy caused by the deposition of monosodium urate (MSU) crystals. The burden of gout is substantial with increasing prevalence of gout globally. The prevalence of Gout in the United States has increased by over 7% in the last two decades. Initially, it was believed that MSU crystal deposits occur only in the joints with the involvement of the periarticular soft tissues, but recent studies have shown the presence of MSU crystal deposition in extra-articular sites as well. Human plasma becomes supersaturated with uric acid at 6.8 mg/dl, a state called hyperuricemia. Beyond this level, uric acid crystals precipitate out of the plasma and deposit in soft tissues, joints, kidneys, etc. If left untreated, hyperuricemia leads to chronic gout characterized by the deposition of tophi in soft tissues such as the joints, tendons, and bursae. With the advent of newer imaging techniques such as DECT, MSU crystals can be visualized in various extra-articular sites. Extra-articular deposition of MSU crystals is believed to be the causative factor for the development of multiple comorbidities in gout patients. Here, we review the literature on extra-articular deposition of urate crystals and the role of dual-energy computed tomography (DECT) in elucidating multi-organ involvement. DECT has emerged as an invaluable alternative for accurate and efficient MSU crystal deposition detection. Future studies using DECT can help determine the clinical consequences of extra-articular deposition of MSU in gout patients.

Gout is a disorder of purine metabolism a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot, and swollen joint. Pain typically comes on rapidly, reaching maximal intensity in less than twelve hours. The first metatarsophalangeal joint is affected in about half of cases. It may also result in tophi, renal stones, or urate nephropathy.1 Commonly, but very large tophi are unusual in chronic gout. Here we present 52 years male patient presenting with unusually large tophi over bilateral foot, with raised serum uric acid levels. In a untreated cases of chronic gout, patients can develop severe destructive poly articular involvement and tophi. Treatment aims at control of serum uric acid levels which can cause regression of tophi. And surgical excision of very large tophi. Keywords: Gout, Arthritis, Tophi, Surgical excision.

Gout is one of the utmost encountered inflammatory arthritis in clinical practice. The purpose of this article is to review the pathophysiology, management and epidemiology of acute and chronic gout. The occurrence of gout throughout the globe has also been documented. Therapies for pain management during gout have also been discussed. Treatment medications of gout can be mainly classified as uricosurics and uric acid synthesis inhibitors, these are discussed in detail in reference to their pharmacokinetics.

Gout is an arthritic syndrome that causes extensive joint damage and discomfort. It is due to an elevated uric acid level in the blood which deposits in the joints. This causes an inflammatory response and joint damage. Gout typically presents as an acute monoarticular attack, resulting in hot, erythematous, swollen, and exquisitely tender joint. Tophaceous gout, which is commonly a later complication of long-standing gout, can rarely be the presenting manifestation of gout. Tophaceous gout is considered a late complication of chronic gout. As early recognition of gout can lead to prompt initiation of treatment and improvement in clinical status, a patient with an alcohol use history who presents with polyarticular swelling and tenderness should raise the suspicion of a tophaceous gout exacerbation even if the patient does not have a documented history of gout.

OBJECTIVES: The aims of this study were to test whether spectral photon-counting radiography (SPCR) is able to identify and distinguish different crystals associated with arthropathies in vitro and to validate findings in a gouty human third toe ex vivo. MATERIALS AND METHODS: Industry-standard calibration rods of calcium pyrophosphate, calcium hydroxyapatite (HA), and monosodium urate (MSU) were scanned with SPCR in an experimental setup. Each material was available at 3 different concentrations, and a dedicated photon-counting detector was used for SPCR, whereas validation scans were obtained on a clinical dual-energy computed tomography (DECT) scanner. Regions of interest were placed on SPCR images and consecutive DECT images to measure x-ray attenuation characteristics, including effective atomic numbers (Zeff). Statistical tests were performed for differentiation of Zeff between concentrations, materials, and imaging modalities. In addition, a third toe from a patient with chronic gouty arthritis was scanned with SPCR and DECT for differentiation of MSU from HA. RESULTS: In both SPCR and DECT, significant differences in attenuation and Zeff values were found for different concentrations among (P < 0.001) and between different materials (P < 0.001). Overall, quantitative measurements of Zeff did not differ significantly between SPCR- and DECT-derived measurements (P = 0.054-0.412). In the human cadaver toe, gouty bone erosions were visible on standard grayscale radiographic images; however, spectral image decomposition revealed the nature and extent of MSU deposits and was able to separate it from bone HA by Zeff. CONCLUSIONS: Identification and differentiation of different crystals related to arthropathies are possible with SPCR at comparable diagnostic accuracy to DECT. Further research is needed to assess diagnostic accuracy and clinical usability in vivo.

Lesinurad is a novel selective uric acid reabsorption inhibitor which has been recently approved for the treatment of the chronic gout. Four simple mathematical spectrophotometric methods have been developed for the quantitative and selective determination of lesinurad in the presence of its oxidative degradation product. Complete oxidative degradation of lesinurad to its degradation product has been done. The developed methods namely, ratio difference spectrophotometric, first derivative of the ratio spectra, mean centering of the ratio spectra and continuous wavelet transform spectrophotometric methods. These methods have been developed and optimized to resolve the existed overlapping between the zero order UV absorption spectra of lesinurad and its oxidative degradation product. The described spectrophotometric methods have achieved selective determination of lesinurad without any interference from the oxidative degradation product. Also, they have been validated and applied for quantitative an...

Objective This study aimed to examine the diagnostic value of serum procalcitonin (PCT) levels for identifying bacterial infection in febrile patients with chronic gouty arthritis. Methods Sixty-six febrile patients with chronic gouty arthritis were divided into non-bacterial infection (n = 45) and bacterial infection groups (n = 21). PCT levels were measured by an immunoassay. Other laboratory parameters, including the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood cells (WBCs), and the neutrophil ratio were extracted from medical records. Receiver-operating characteristic curves were used to evaluate diagnostic values and accuracy. Results Serum PCT levels, the ESR, CRP levels, WBC count, and neutrophil ratio were not different between the groups. To assess the ability of PCT to discriminate bacterial infection in febrile patients with chronic gouty arthritis (cut-off value: 0.5 ng/mL), the sensitivity and specificity of PCT were 22.2% and 61.5%, respectively. The area under the curve (AUC) of serum PCT levels was 0.526. The AUCs of related inflammatory indicators were 0.530 for the ESR, 0.635 for CRP, 0.577 for the WBC count, and 0.712 for the neutrophil ratio. Conclusion Serum PCT levels may not be a good biomarker for bacterial infection in febrile patients with chronic gouty arthritis.

Background: Gout is one of the most common inflammatory arthropathies, and the pathogenesis is well understood. In Australia, most patients with chronic tophaceous gout (CTG) are treated by general practitioners (GPs). Urate-lowering therapy, if adhered to continuously, can suppress the disease, reduce the likelihood of flares and prevent long-term complications such as disfiguring tophi and joint damage. Many rheumatology societies recommend a treat-to-target (T2T) approach, lowering serum urate to 0.35 mmol/L or below with urate‑lowering therapy. Objectives: The aim of this article is to discuss inconsistencies in treatment guidelines, identify patient and physician barriers to optimal gout care, explain why a T2T approach is appropriate and make a series of recommendations that are practical for GPs. Discussion: Despite an in-depth understanding of this controllable disease and the availability of simple, safe treatments, chronic gout remains poorly managed. The development of Australian gout guidelines that are easily implemented by GPs is vital and overdue.

Introduction Pegloticase, a potent uricolytic biologic enzyme, has been shown to be an effective therapeutic option in patients with uncontrolled gout. However, there are limited data on clinical response after a gap in therapy and retreatment with pegloticase. Case Series This report describes four patients with chronic gout who were successfully managed with pegloticase and were retreated following a gap in therapy. Patient charts from a practice-based rheumatology clinic were retrospectively analyzed; four male patients, aged 70–75 years, with chronic gout and a more than 4-week gap in pegloticase therapy were reviewed. Before pegloticase treatment, patients had received allopurinol or febuxostat, but they continued exhibiting symptoms, including visible tophi and serum uric acid (SUA) levels of 5.2–10.2 mg/dL (309–607 μmol/L), despite oral urate-lowering therapy. The first pegloticase treatment (8-mg infusion every 2 weeks) lasted 22–124 weeks. Pegloticase resolved tophi and improved SUA to below 1.5 mg/dL (less than 89 μmol/L); however, patients discontinued pegloticase because of symptom resolution, poor adherence, or personal reasons. Following treatment gaps (12–156 weeks), symptoms and SUA levels increased and patients were retreated with pegloticase (4–147 weeks). In three of four patients, reinitiating pegloticase lowered SUA levels to below 1.0 mg/dL (less than 59 μmol/L) and resolved symptoms. One patient experienced an infusion reaction and discontinued; no infusion reactions, gout flares, or adverse events occurred among the other three patients. Conclusion Retreatment with pegloticase after a gap in therapy appears to be an effective and tolerated option in prior responders. Funding Horizon Pharma.

Objetivo: O objetivo desta revisão é fornecer informação atualizada e orientações práticas sobre a abordagem da gota na Atenção Primária à Saúde. Métodos: Foram pesquisadas normas de orientação clínica, revisões sistemáticas, meta-análises e estudos originais publicados entre 1 janeiro de 2011 e 31 dezembro de 2016, nas línguas inglesa, portuguesa e espanhola. Resultados: Os fármacos de primeira linha no tratamento da gota aguda são os anti-inflamatórios não esteroides, a colchicina e os corticoides, em monoterapia ou associação. Na gota crônica são usados hipouricemiantes, sendo a primeira linha o alopurinol. O febuxostate e os uricosúricos são alternativas ao alopurinol em casos de intolerância ou ineficácia. A profilaxia das crises de gota agudas está recomendada quando se inicia o tratamento hipouricemiante durante pelo menos 6 meses. Conclusão: A abordagem correta da gota deve fazer parte das competências de um médico especialista em Atenção Primária à Saúde de modo a prestar cuidados adequados à comunidade.

Flare prophylaxis is recommended during urate-lowering therapy (ULT) despite lack of proven benefit especially when initiating febuxostat. We investigated if colchicine or steroids administration during initiation of febuxostat for chronic gouty arthritis reduces the frequency and/or severity of acute gout flares.Patients with confirmed diagnosis of gout starting febuxostat were retrospectively studied. Frequency, severity, and length of flares were analyzed. Assessment of severity based on a visual analog scale (VAS).Two hundred and seventy-three patients were studied. The mean dose of colchicine and steroids was 0.53 ± 0.15 mg PO QD and 7.55 ± 1.30 mg prednisone equivalent PO QD; while the duration was 6.13 ± 1.14 and 6.20 ± 1.36 months, respectively. Subjects treated with colchicine and steroids suffered fewer total flares (0.30, 0.96 vs 2.47, p = .000), fewer flares from 0 to 3 months (0.26, 0.71 vs 1.72, p = .000), less severe flares assessed by VAS than those without prophylactic therapy (3.65, 3.49 vs 5.54, p = .000). Both total flares (p = .003) and flares from 0 to 3 months (p = .008) of the colchicine group were fewer than the steroids group. There were no significant differences in length of flares among groups (p = .815). Both colchicine and steroids were well tolerated.The use of colchicine or steroids prophylaxis reduces the frequency and severity of acute gout flares during initiation of febuxostat for chronic gouty arthritis. Colchicine is superior to steroids in flares prophylaxis. Prophylactic therapy with colchicine 0.5 mg PO QD or steroids 7.5 mg prednisone equivalent PO QD for 6 months is suggested.

Gout is the most common inflammatory arthritis in humans. Gout treatment includes rapid initiation of anti-inflammatory medications for acute attacks and chronically treating with urate lowering drugs as well as chronic anti-inflammatory prophylaxis. Areas covered: This review aims to provide an overview and discussion of the safety concerns of current treatment options available for gout. Expert opinion: Gout is a curable disease with appropriate treatment. The advent of new therapies provides encouraging opportunities to improve gout management. However, clinicians should be aware of some of the safety concerns of medications used to treat acute and chronic gout. When prescribing medications for gout one has to be mindful of the presence of comorbidities commonly affecting gout patients that may affect drug safety and efficacy, especially in the elderly and in patients treated with multiple drugs. The benefits of gout drugs, usually, outweigh their safety concerns. Studies are needed in gout patients with chronic kidney disease and/or cardiovascular disease, so that escalation of dosing /combination of anti-inflammatory drugs needed to suppress gouty inflammation as well as escalation of dosing/combination of urate lowering drugs needed to achieve target serum urate level will lead to better understanding of gout treatment safety issues.

Due to the increasing prevalence of gout, particularly in old age, the disease is becoming of increasing importance in Germany. Gout is one of the most common forms of recurrent inflammatory arthritis and is induced by the deposition of monosodium urate crystals in synovial fluid and other tissues. The principal goals of therapy in chronic gout are the symptomatic treatment of the acute joint inflammation and the causal treatment of the underlying metabolic cause, the hyperuricemia. Only a consistent and permanent reduction of the serum uric acid level ultimately results in an efficient avoidance of further gout attacks and therefore the prevention of structural damage. Due to an often inadequate treatment of gout, the target of healing the disease is often not achieved. A correct and timely diagnosis and adequate assessment of comorbidities associated with gout are, however, of substantial importance for patient and physician to achieve remission of the disease. In order to create a solid basis for a timely and effective treatment of affected patients, in 2016 the German Society of Rheumatology (DGRh) initiated the development of S2e guidelines on gouty arthritis for specialists. This article summarizes these S2e guidelines on the management of gouty arthritis in the specialist sector.

WOS: 000439909900007 Gout disease is an inflammatory disease triggered by monosodium urate monohydrate crystals that accumulate in tissues due to hyperuricemia, which usually seen in males over 40 years. Chronic obstructive polyarthritis and chronic gouty arthritis coursing with tophi may develop in patients who are not adequately treated. Tophi are frequently observed in hand-foot fingers, olecranon bursa, prepatellar bursa, ear helix and achilles tendon. As for that in our case, tophi were present in bilateral lumbar paravertebral muscles and left cervical paravertebral muscles in addition to hand-foot joints, ear helix and olecranon bursa. In the patient who started colchicine 1 mg/day and allopurinol 300 mg/day, the joint pain improved and the tofus in the ear helix disappeared completely at the 6th month control. In conclusion, it should be kept in mind to clinical practice that in chronic cases, tophi may localized in atypical regions other than classical localizations, and tophus may lead to joint destruction due to delayed treatment.

Gout is a common inflammatory arthropathy with a high prevalence worldwide. Increased levels of uric acid in the blood lead to deposition of monosodium urate crystals in the joints, inflammation, and pain. Acute gout attacks are often sudden, monoarticular, and typically resolve within a week, whereas chronic gout is often polyarticular with baseline pain between attacks. In chronic gout, depositions of uric acid known as tophi can form throughout the body. Despite the high prevalence of gout and the frequency with which tophi occur, ulceration over tophi is surprisingly rare. We report the case of a 38-year-old man, undiagnosed with gout, who presented to clinic for evaluation of ulcers with chalky white granules. The wounds were determined to be ulcerated tophaceous gout. Risk factors for ulceration over tophi and reported treatments are discussed.

Traditional herbal medicine in Indonesia is still in great demand and popular in society. The Indonesian government regulations state that herbal medicine should not contain chemical drug due to the toxic effect of uncontrolled consumption. Allopurinol is one of the drugs commonly added to herbal medicine for the treatment of chronic gout. Paper-based analytical device is one of the latest forms of analysis that has been widely used for the identification of chemical elements, environmental contamination, bacteria, and many more. In this study, experiments were conducted using Whatman filter paper No. 1, No. 2, and No. 4 and Whatman chromatography as a paper, and 9 colorimetric reagents were tested for allopurinol detection in herbal medicine. There were 5 specific reagents that reacted positively with allopurinol and only 3 reagents that can be applied to the paper, that is, Folin-Ciocalteu, Tollens, and p-DAB reagent. The results of the optimization show that the most optimal immersion time was 60 minutes with a drying time of 30 minutes at 50°C. Each filter paper has different characteristic; however, there was no significant difference when all of the papers were used as PAD for allopurinol detection.

Background Vitamin D has immunomodulatory, anti-inflammatory properties and important role in bone metabolism. Effects of vitamin D supplementation in musculoskeletal diseases are well known, but it is unknown if local application of vitamin D can have an anti-inflammatory potential. Aims The aim of this study was to investigate local influence of vitamin D on inflammation, pain, redness and swelling of the affected joint in acute and chronic gouty arthritis. 40 patients with acute gouty arthritis and 40 patients with chronic gouty arthritis were included in study. Methods We did topical application of cholecalciferol in a dose of 180,000 IU daily through seven days on the affected joint for one hour. Local changes of the affected joint such as swelling and redness were observed. Also, serum samples were taken on a 1st, 3rd and 7th day of application in order to measure levels of vitamin D, urates, calcium and C reactive protein. Results We found that local application of vitamin D increased its serum levels in both groups of patients while urates level, swelling, redness and pain was reduced. Effect of vitamin D on pain, redness and inflammation was stronger in a group with acute inflammation. Conclusion Local application of vitamin D may be linked to the reduction of acute and chronic inflammation in gouty arthritis. Relationship between vitamin D and urates in inflammatory process should be investigated further.

Objective We hypothesized that chronic gouty arthritis patients would develop an immune response to type II collagen that would be revealed by the presence of anti-type II collagen (CII) antibodies in serum, which may in turn be involved in progression to non-remitting arthritis. Methods Chronic gouty arthritis was defined as crystal-confirmed gout in patients with no pain-free intercritical period, with or without the presence of tophi, who did not have clinical features of other forms of chronic arthritis. Age-matched gout patients suffering acute gouty attacks who had definite intercritical periods were selected as a control group. Four RA patients who had active disease were enrolled as a positive control group. Anti-CII antibodies were quantified in patient sera via ELISA using a human IgG anti-CII antibody assay kit. Correlations between anti-CII levels and clinical parameters were sought. Results Fifteen chronic gouty arthritis patients were identified. The anti-CII level was significantly higher among subjects with chronic gout compared to controls, but did not significantly differ in control gout patients during acute attacks and in the intercritical periods. Five patients with chronic gouty arthritis had anti-CII antibody levels higher than 200 AU/mL, whereas only one control gout patient exhibited this feature. Two of four patients with active RA had anti-CII antibody levels higher than 200 U/mL.Patients with tophi had significantly higher anti-CII levels than those without, whereas patients showing radiographic erosion tended to have higher anti-CII levels than those without. Conclusion Patients with chronic gouty arthritis had significantly higher levels of anti-CII antibodies than control gout patients. Such antibody production would be triggered by initiation of cartilage damage but may also play a role in perpetuation of inflammation.

Introduction The aim of this study was to assess the distribution of bone erosions in the feet of patients with gout using CT and thereby to test the hypothesis that gout is an asymmetric arthropathy. Methods CT scans of both feet were obtained from 25 patients with chronic gout. CT scans were scored for bone erosion using a semi-quantitative method based on the rheumatoid arthritis MRI scoring system (RAMRIS). CT bone erosion was assessed at 22 bones in each foot (total 1,100 bones) by two independent radiologists. Symmetry was assessed by two methods: (i) comparing right and left foot scores for each patient; and (ii) calculating the proportion of paired joints with or without erosions. Results Observer agreement was excellent (intra-class correlation coefficient 0.92). In the group overall, the difference in scores between the feet was not significant (Student's t-test P = 0.8). In 17 of 25 patients, the difference in erosion scores between the two feet was less than the inter-observer difference. In 24 of 25 patients, the proportion of paired joints was greater than 0.5, indicating symmetric disease. Conclusions Erosive disease from gout is, in fact, a symmetric process in our patient group. This finding is contrary to the established view of gout as an asymmetric arthritis and lends new insight into the behaviour of this common disease.

Background Lowering plasma urate in subjects with gout is associated with an increase in flares because of an altered equilibrium between soluble urate and uric acid crystals.1 Details of the relationship between plasma urate lowering and gout flares have not been fully delineated. Pegloticase is a mammalian recombinant uricase conjugated to polyethylene glycol approved for the treatment of chronic gout refractory to conventional oral urate lowering therapy.2–4 Results from the two 6 month randomised clinical trials (RCTs) of pegloticase showed that during months 1–3, there was an increase in pegloticase-treated subjects experiencing gout flares vs those receiving placebo. However, the reported analysis did not separate results for subjects who did and did not respond to pegloticase with a sustained reduction in plasma urate levels or relate flares to plasma urate levels. Objectives To determine factors associated with the occurrence of flares in subjects who did and did not respond to pegloticase in the two RCTs for this therapy. Methods This analysis used results from 2 pivotal RCTs2 of pegloticase (8 mg every 2 weeks [q2] or every 4 weeks [q4]) vs placebo in subjects with chronic refractory gout. A responder was defined as a subject with plasma urate Results There were increases in the frequency of subjects experiencing flares and the mean flare frequency in the pegloticase group vs placebo during the first 3 months of the trial (figure 1A). In contrast, there were marked reductions in both outcomes during months 3–6 (figure 1B). The increase in flares in the first 3 months was most evident (p=0.0006) and the decrease during the second 3 months was least marked (p=0.0006) in subjects receiving q4 pegloticase. Previous analysis indicated that q2 pegloticase caused persistently lowered plasma urate in responders, whereas q4 administration resulted in a more saw tooth pattern.5 Multivariate linear regression analysis indicated that the only variable associated with flares in the treated subjects was the absolute change in plasma urate prior to these events. Assessment of plasma urate at both 2 weeks and immediately before flares indicated that larger differences between these two values were associated with increased flare occurrence (p=0.002). Conclusions Flares associated with pegloticase treatment in subjects with chronic refractory gout were increased most markedly in responders to monthly administration and were significantly associated with fluctuations in plasma urate levels. Such fluctuations are much more common with monthly administration of pegloticase vs the recommended biweekly treatment regimen. References [1] Wortmann RL, et al. Clin Ther2010;32:2386. [2] Sundy JS, et al. JAMA2011;306:711. [3] Mandell BF, et al. Arthritis Rheumatol2016;68(suppl 10):212. [4] Mandell BF, et al. Arthritis Rheumatol2017; 69(suppl 10):2054. [5] Lipsky PE, et al. Arthritis Res Ther2014;16:R60. Disclosure of Interest L. Calabrese: None declared, T. Fields Consultant for: Horizon Pharma, Takeda, Ironwood, Speakers bureau: Horizon Pharma, Takeda, Ironwood, A. Yeo Consultant for: Horizon Pharma, P. Lipsky Consultant for: Horizon Pharma

Background In 2016 EULAR evidence based clinical guidelines on Gout treatment have been updated.1 Objectives to assess current daily practice physicians’ approach to management of chronic gout patients Methods a cross-sectional anonymous survey had been offered to hospital and outpatient departments physicians dealing with gout patients resulting in 97 back-feed replies yielded. This publication deals with chronic gout treatment practice. Results all survey participants were divided into 3 groups. Group 1 consisted of 18 rheumatologists (professional experience median 19.6 years, range 1 to 43), group 2 included 60 general practitioners (GP, professional experience 27; 4–47), group 3 included other specialists (cardiologists, surgeons etc.) who reported frequent contacts with gout patients (professional experience 16.5; 1–44). Rheumatologists reported to contact median 15 (range 2–40) gouty subjects per month, while group 2 reported to see 31 – 10 and group 3 consults 41 – 12 patients per month. All rheumatologists and 45 GPs reported initiation of allopurinol or febuxostat after gouty arthritis resolution, while 11 general practitioners did not start antihyperuricemic drugs in subjects with kidney and/or cardiovascular comorbidities. In Group 3 only 6 responders had experience of antihyperuricemic drugs administration, but 3 of them reported allopurinol initiation during gout flare. Only 2 rheumatologists and 2 GPs were aware of gout flare low dose colchicin prophylaxis during allopurinol dose adjustment. Administration of maximal allopurinol daily maintenance doses over 300 mg was reported only by 7 rheumatologists and 7 GPs. Other specialists did not have any personal experience of allopurinol dose adjustment. By responders’ assessment every 2–3 patient continues to experience gout flares in spite of prescribed treatmen Conclusions intensive educational intervention is urgently required to change current practice of chronic gout treatment in Russia. Reference [1] Richette P, et al. 2016updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis2017;76:29–42 Disclosure of Interest None declared

Background in everyday practice chronic gout patients are frequently consulted by general practitioners, surgeons, cardiologists and other specialists. In general, chronic gout patients have been reported to be quite incompliant, but it remains unclear whether low compliance depends on the specialty of the prescribing physician.1 Objectives to compare the clinical course of gout in patients consulted by different specialists and to identify factors of low patients’ compliance in Russia. Methods cross-sectional study included 56 chronic gout patients aged 31 to 82 (median 54 years). Average gout symptoms duration was 6.8 years, average attacks frequency was 6.4 per year. Tofi were present in 21.4% of patients. All subjects were divided into three groups: Group 1 consisted of treatment naive patients at primary rheumatologist visit, Group 2 and Group 3 included patients who had previously been treated. Group 2 subjects were visiting both non-rheumatologists and rheumatologists. Group 3 were managed by rheumatologists strictly according to the EULAR evidence-based recommendations.2 Results Group 1 primary consulted rheumatologists at the age of 47.3±14.5, Group 2 patients were assessed at the age of 58.4±15.2, and Group 3 were aged 51.2±13.5. Disease symptoms duration was maximal in Group 2 (10.6±10.6 years) while 5 years in Groups 1 and Group 3. Flares frequency was the lowest in Group 3 (2.2±1.8 per year), while in Group 2 it was extremely high – (10,58±10,56 per year). The incidence of tofi and urolithiasis was lowest in the Group 3 whereas every third treatment naive patient had tophi or/and urolythiasis. To relieve gouty arthritis vast majority of patients used NSAIDs, though at 50% strength of the recommended dose. Only 9%–14% of flares were controlled by colchicine in Groups 2 and 3. Colchicine prevention of flares was prescribed only in 45% of cases by rheumatologists. The most frequent urate-lowering therapy (ULT) was allopurinol, it was taken only by 63% of patients of the third group and 35.7% in the second group. While patients in the third group took the drug daily, the other patients did not follow the administration scheme. Serum creatinine level was the lowest (87.5±16.8 μmol/L) in Group 3, being the highest in treatment of naive patients (102.7±30.0 μmol/L). Serum uric acid target level was achieved only in the compliant Group 3 patients (343 μmol/L), while Group 2 levels varied between 462–546 μmol/L, being the highest (625 μmol/L) in treatment naive Group 1. Low compliance risk factors were: age under 45, absence of comorbidity and long term multiple drugs consumption. Conclusions chronic gout patients’ compliance and quality of patient management can be assessed as alarmingly low. Rheumatologists adhering to EULAR evidence-based approach to gout management can actually achieve recommended treatment targets. Both general practitioners and other specialists are in need of consistent educational program on gout management. Younger and comorbidity-free gout patients should be encouraged to follow attending physician’s recommendations. Reference [1] Burrell A, Wong P, Ollendorf D, et al. Defining compliance/adherence and persistence: ISPOR Special Interest Working Group. Value Health2005; 8:A194–5. Disclosure of Interest None declared

Gout is the most common inflammatory arthritis in adults. Given the increasing prevalence of gout and associated comorbidities, there is a growing need for better therapeutic options. While current treatment options satisfactorily control the disease in some patients, many patients, especially those with associated comorbidities, have contraindications to current treatments and need more treatment options. New drugs are needed to further improve our treatment, especially in patients with associated comorbidities. The duration of therapy for acute and chronic gout as well as combination of therapies, recommended by the American College of Rheumatology (ACR) guidelines, need to be further studied. The past decade has been an exciting time for gout research with significant advances in our understanding of disease pathogenesis and its treatment. The new ACR guidelines have improved gout visibility and will improve gout awareness and treatment in the future. With growing treatment options, gout is becoming a disease that can be cured.

Objective Comorbidity is an important concern for chronic gout patients. We evaluated the relationship between comorbidity profiles and gout in Taiwan aborigines and Taiwanese Han. Methods We used the claims data from the Taiwan national health insurance database for 2004 to 2006. Physician-diagnosed gout and comorbidities were coded using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Total sampling from Pingtung County of southern Taiwan included 37,482 aborigines (gout cases, n = 3906 and controls, n = 33,576) and 37,451 Han (gout cases, n = 1115 and controls, n = 36,336). Results In 2006, the gout prevalences were 10.42% and 2.98% (prevalence ratio [PR] = 3.50) in the aborigines and Han general populations, respectively. The prevalences of uric acid nephrolithiasis and tophi were higher in aborigines (0.42% and 0.30%, respectively) than in Han (0.09% and 0.04%, respectively). When stratified by comorbidity status, the prevalences of gout were 4.49% and 27.34% in aborigines and 1.52% and 9.44% in Han (approximate PR = 3.00). Similarly, the prevalence ratios of gout in the comorbidity group, compared with the non-comorbidity group, were 6.09 in aborigines and 6.23 in Han. Multivariate odds ratios [ORs] showed that hypercholesterolemia, hyperglyceridemia, essential hypertension and renal insufficiency were the common comorbidities of gout (OR ≥ 1.63); heart failure exerted a significant effect only in aborigines (OR = 1.55). For five comorbidity factors, patients with multiple comorbidities had higher gout prevalence (maximum OR = 12.90). Conclusion Gout prevalence was higher in aborigines, both with and without comorbidities, than in Han. The comorbid diseases and comorbidity aggregations showed a substantial association with gout occurrence in both ethnicities.