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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.

Febuxostat used for the treatment of patients with arthritis littered with Hyperuricemia and is utilized in its Chronic Management. a number of the internal organ adverse effects have diode to the employment of febuxostat replaced with with allopurinol drug. Febuxostat, associate degree compound accelerator matter, achieves its therapeutic result by decreasing humour acid. At therapeutic concentrations it is not expected that Febuxostat will inhibit different enzymes which are involved in purine and pyrimidine synthesis and their metabolism. Metabolism of Febuxostat is done by conjugation via uridine diphosphate glucuronosyltransferase (UGT) enzymes and also by UGT1A1, UGT1A3, UGT1A9, and UGT2B7 and reaction via hemoprotein P450 (CYP) enzymes as well as CYP1A2, 2C8 and 2C9 and non-P450 enzymes. Febuxostat is eliminated primarily through each viscus and excretory organ pathways. Febuxostat could cause heart issues that may result in coronary failure, could cause issues within the blood vessels that visit your brain. this could conjointly result in stroke, urarthritis flare-ups and Liver injury. Some facet effects of febuxostat could occur that sometimes don't would like medical attention. We conclude from our review, vessel Death urarthritis patients with established vessel (CV) illness treated with febuxostat had a better rate of CV death compared to those treated with allopurinol drug in a very CV outcomes study.

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.

Relatório de Estágio do Mestrado Integrado em Ciências Farmacêuticas apresentado à Faculdade de Farmácia No presente trabalho estão incluídos os relatórios do estágio realizado em Farmácia comunitária (Farmácia São José, Coimbra) e do estágio realizado em Indústria Farmacêutica (Bluepharma, S. A., Coimbra), onde é elaborada um análise S.W.O.T. (análise dos pontos fortes (strenghts), dos pontos fracos (Weaknesses), das oportunidades (opportunities) e das ameaças (threats) detetados ao longo dos mesmos). É também apresentada a monografia intitulada "Gota tofácea crónica e seu tratamento" , onde é feita uma abordagem à Gota, à sua fisiopatologia, aos sinais, sintomas e possível evolução da doença, às opções terapêuticas existentes, atualmente , para o tratamento da mesma e às medidas não farmacológicas a adotar pelos doentes. A gota é uma das formas de artrite inflamatória mais comum no mundo . É estimado que na população portuguesa a prevalência desta doença seja de 1,3% , estando em crescimento, com o surgimento da primeira crise entre os quarenta e os sessenta anos e sendo mais frequente nos homens. É fundamental sensibilizar os doentes para a importância de um diagnóstico precoce e início de uma terapêutica adequada e mudança do estilo de vida. A gota tofácea crónica consiste na fase clínica mais grave e ocorre em doentes com evolução duradoura da doença ou que não realizam ou aderem à terapêutica. A variedade de opções terapêuticas existentes atualmente, no mercado e em estudo, realça a possibilidade de os doentes viverem com qualidade de vida, através do tratamento dos sintomas da gota e da prevenção de crises agudas recorrentes. The following document presents my internship report in community pharmacy (Farmácia São José, in Coimbra) and my internship report in pharmaceutical industry (Bluepharma, S. A. in Coimbra) and it's presented as an S.W.O.T. analysis (analysis of strengths, weaknesses, opportunities and threats detected during both of the internships). This document also presents the monograph entitled "Chronic tophaceous gout and its treatment", where a review on gout is made , on its pathophysiology, the signs, symptoms and possible evolution of the disease, on the therapeutic options currently available for its treatment and on the non-pharmacological measures to be taken by patients. Gout is one of the most common forms of inflammatory arthritis in the world. It is estimated that in the Portuguese population the prevalence of this disease is 1.3% , growing potential, with the onset of the first crisis between forty and sixty years of age and being more frequent in men. It is essential to sensitize patients to the importance of an early diagnosis and the beginning of an adequate and lifestyle change. Chronic tophaceous gout is the most severe clinical stage and occurs in patients with long-term disease progression or who do not undergo or adhere to therapy. The variety of therapeutic options currently available, on the market and under study,enhances the possibility for patients to live with quality of life, through the treatment of gout symptoms and the prevention of recurrent acute crises.

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.

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.

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.

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.

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.

Background Ultrasonography (US), magnetic resonance imaging (MRI), computed tomography (CT), and X-ray are the alternative diagnostic modalities used to identify affected joints and surrounding tissues (tophi, erosions and synovitis) in gout patients, but the potential of each method for sequential assessment of disease regression in pts receiving urate-lowering therapy is not sufficiently studied [1] Objectives Comparison of US, CT, X-ray and MRI efficacy for sequential assessment of affected joints in pts treated with urate-lowering agents. Methods The open prospective study was conducted in 2013–2015 yy at V.A. Nasonova Research Institute of Rheumatology. 22 pts with crystal-verified gout (4 (15%) f and 18 (85%) m), mean age – 54,5±12,7 years, were included. The dose of allopurinol administered in all pts was adjusted by titration starting from 100 mg/day. Instrumental diagnostic examination (US, MRI, CT and plain X-ray of knee joints) was performed at baseline and after one year of follow up. US of knee joints was performed using multi-frequency linear array transducer, at 7 to 17 MHz frequencies; for MRI examination “Esaote Artrosan 0.25TI” was used, GE “Light Speed” - for CT scans, and Stephanix – for plain X-ray examination. Applied descriptive statistics STATISTICA 10.0 (StatSoft/Inc., USA) package was used for statistical analysis. Results Mean serum level of uric acid decreased from 568±115 μmol/l to 302±135 μmol/l. The target level ( Conclusions MRI and US, as for synovitis, erosions and tophi dynamics, are comparable, at that for erosions MRI is more accurate. CT is the most informative approach to monitor intraosseous tohhi regression. X-ray is low- informative modality for sequential assessment of gout. References Grainger R, Dalbeth N, Keen H, et al. Imaging as an outcome measure in gout studies: report from the OMERACT gout working group. J Rheumatol 2015; 42(12):2460e4. Disclosure of Interest None declared

Objectives To evaluate the prevalence of ultrasonographic gout specific signs of foot joints. Methods This is a cross-sectional study which includes 15 patients with chronic gout, defined according to the American College of Rheumatology criteria (ACR 1977). Ultrasound (US) examination was performed using a high-frequency linear probe (Toshiba Xario®, frequency (8–14 MHz)) in B mode. 330 articular sites were studied at their dorsal surface. The ultrasound has objectified the presence of two signs: hyperechoic band over the superficial margin of the articular cartilage described as a double contour (DC) and tophaceous deposits at the joint cavity. Results The mean age at onset was 54.7±12,6 years, and the median diagnosis duration was 0 (0.3) years). The results of the US examination are summarized in Table 1. Conclusions This study showed a predilection for the gout specific ultrasound signs (DC and tophaceous deposits) in the tarsometatarsal and metatarsophalangeal joints, especially in the first MTP. The contribution of musculoskeletal ultrasound seems to be very interesting to objectify the presence of gout specific signs of the foot joints. Disclosure of Interest None declared

Objectives To compare the prevalence of ultrasonographic gout specific signs at the dorsal and plantar surfaces of the metatarsophalangeal joints (MTP). Methods This is a cross-sectional study which includes 15 patients with chronic gout, defined according to the American College of Rheumatology criteria (ACR 1977). Ultrasound (US) examination was performed using a high-frequency linear probe (Toshiba Xario®, frequency (8–14 MHz)) in B mode. 150 articular sites were studied at their dorsal and plantar surfaces. The ultrasound has objectified the presence of two signs: hyperechoic band over the superficial margin of the articular cartilage described as a double contour (DC) and the tophaceous deposits at the joint cavity. We compared the prevalence of the two signs between the dorsal and palmar surfaces at each site studied. Results The mean age at onset was 54.7±12,6 years, and the median diagnosis duration was 0 (0.3) years). The results of the US examination are summarized in Table 1. Conclusions Our study suggests that globally, DC predilect significatily in dorsal than in plantar surfaces of MTP joints. These results should be verified on a larger population. Disclosure of Interest None declared

Objectives To compare the prevalence of ultrasonographic gout specific sign double contour between the dorsal and palmar surfaces of the hand joints. Methods This is a cross-sectional study which includes 15 patients with chronic gout, defined according to the American College of Rheumatology criteria (ACR 1977). Ultrasound (US) examination was performed using a high-frequency linear probe (Toshiba Xario®, frequency (8–14 MHz)) in B and Doppler modes. 560 articular sites were studied at their dorsal and palmar surfaces. We compared the prevalence of the hyperechoic band over the superficial margin of the articular cartilage described as a double contour (DC) between the dorsal and palmar surfaces at each site studied. Results The mean age at onset was 54.7±12,6 years, and the median diagnosis duration was 0 (0.3) years). The results of the US examination are summarized in Table 1 Conclusions Our study suggests that globally, DC predilect significatily in dorsal than in palmar surfaces of hand joints. These results should be verified on a larger population. Disclosure of Interest None declared

Objectives To evaluate the prevalence of ultrasonographic gout specific signs of hand and fingers joints. Methods This is a cross-sectional study which includes 15 patients with chronic gout, defined according to the American College of Rheumatology criteria (ACR 1977). Ultrasound (US) examination was performed using a high-frequency linear probe (Toshiba Xario®, frequency (8–14 MHz)) in B mode. 540 articular sites were studied at their dorsal surface. The ultrasound has objectified the presence of two signs: hyperechoic band over the superficial margin of the articular cartilage described as a double contour (DC) and the tophaceous deposits at the joint cavity. Results The mean age at onset was 54.7±12,6 years, and the median diagnosis duration was 0 (0.3) years). The results of the US examination are summarized in Table 1. Conclusions This study showed a predilection for the gout specific ultrasound signs (DC and tophaceous deposits) of the wrist and MCP joints. The contribution of musculoskeletal ultrasound seems to be very interesting to objectify the presence of gout specific signs in the hand and fingers joints. Disclosure of Interest None declared

Gout is characterized by recurrent episodes of acute inflammation of joint structures, called gout flares, and flares are commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDs). The objective of the study was to evaluate risk factors associated with acute kidney injury (AKI) attributed to NSAIDs in a cohort of patients who were exposed to NSAIDs to treat gout flares prior to urate-lowering therapy. Retrospective analysis of a nested cohort of 983 gout patients in whom general variables (age, gender, renal function, ethanol intake, hypertension, hyperlipidemia, diabetes, vascular events, diuretic use) and also variables related to gout and severity of gout (serum urate levels, number for flares per year, presence of tophi, joint distribution, X-ray involvement, previous urate-lowering therapy) were available for analysis. Outcomes considered were loss of renal function attributed to NSAID prescription following the RIFLE classification for (risk, injury, and failure) for acute renal events. Variables associated with increased risk in Kaplan-Meier survival analysis were tested with multivariable Cox survival analysis, using time from onset of gout to the event as time exposed to NSAIDs. Of 983 patients, 55 (5.6%) experienced AKI; the number of flares in the year previous to the renal event and polyarticular joint distribution were associated with higher risk of renal events. Other variables previously described in the literature, such as previous chronic renal disease, use of diuretics, and presence of previous vascular events, were also independently associated with increased risk of AKI. Interestingly, patients who had been previously prescribed allopurinol showed a lower risk of acute renal events. In addition to classic risk factors, the number of flares and extensive joint distribution were associated with higher risk for renal injury in patients with gout, while previous prescription of allopurinol was associated with lower risk. This work was partially supported by a grant from Asociacion de Reumatologos del Hospital de Cruces. No funding was received for article processing charges. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. Fernando Perez-Ruiz, as corresponding author, warrants that this is an original work, has not been published, except in abstract form for congress presentation, and is not being considered for publication in any other journal. I take full responsibility for the content of the work and guarantee that the results are a true reflection of the facts to the best of my knowledge. F. Perez-Ruiz designed the study, collected data, made statistical analysis, and wrote the manuscript. No external assistance has been received.

Objective. The aim of this study was to systematically review outcome domains and measurement tools used in gout trials and their accordance with the preliminary OMERACT gout recommendations published in 2005. Methods. Randomized controlled trials (RCTs) and quasi-RCTs investigating any intervention for gout published up to February 2013 were included. Recruitment start dates and all measured outcomes were extracted. Risk of bias (RoB) was assessed with the Cochrane Collaboration tool. Numbers of OMERACT domains were compared for trials at low vs unclear/high RoB and for recruitment start date before 2005 or 2005 and later. Results. Of 9784 articles screened, 38 acute and 30 chronic gout trials were included. Mean (s.d.) number of OMERACT outcomes was 2.9 (1.1) (out of 5) and 2.5 (1.2) (out of 9) for acute and chronic gout trials, respectively. Health-related quality of life, participation and joint damage imaging were not assessed in any trial. Tools used to measure individual domains varied widely. There were no differences in the number of OMERACT outcomes reported in acute or chronic gout trials recruiting before 2005 vs 2005 or later [mean (s.d.): 3.0 (1.1) vs 3.5 (1.3), P = 0.859 and 2.7 (1.1) vs 2.8 (1.4), P = 0.960, respectively]. While both acute and chronic trials at low RoB reported more OMERACT domains than trials at unclear/high RoB, these differences were not significant. Industry-funded trials and trials performed by OMERACT investigators reported more OMERACT outcome domains. Conclusion. We found no appreciable impact of the OMERACT recommendations for gout trials to date

Gout is the only curable form of arthritis, yet only a third of patients with chronic gout are receiving appropriate urate-lowering therapy. Our Drug review discusses the available treatment options and their properties, followed by sources of further information.

Objective: To assess the urate-lowering efficacy and safety of Febuxostat versusAllopurinol in subjects with hyperuricemia and gout. Study design: Randomized controlled trial.Place and duration of study: Department of Orthopaedic and Trauma Surgery Mardan MedicalComplex Teaching Hospital Bacha khan Medical College Mardan from February 2012 to March2013. Material and Methods: Fifty patients of chronic gout and hyperuricemia fulfilling theinclusion criteria were divided into two equal groups by random method having 25 patients eachand received either a fixed dose(80 mg) of Febuxostat (Group A) or Allopurinol (Group B) 300mgonce daily for 16 weeks. The primary end point was the percentage of patients reaching serumurate level