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Jaccoud’s arthropathy (JA) is a deforming arthropathy observed mainly in patients with systemic lupus erythematosus. We report the case of a 41-year-old Brazilian man with a 10-year history of intermittent monoarthritis followed by bouts of polyarthritis affecting large and small joints. He presented deformities typical of JA and subcutaneous nodules. Histopathological findings of a nodule biopsy were consistent with gouty tophi. To our knowledge, this is the first report of JA secondary to chronic gout.

Background Appropriate evaluation of disease or treatment outcomes requires a good understanding of the aspects of the disease and its consequences that actually matter to patients. The OMERACT process has identified several domains of outcome measurement for chronic gout, but patient involvement has only been briefly described. Objectives To make the results of patient involvement more explicit, the current study reports on an exercise carried out in the early part of the OMERACT domain identification process. Methods Patients with gout were asked to identify areas of life affected by gout. These areas were rated (0-10) and ranked for importance by a second group of patients with gout recruited from both primary care and a rheumatology clinic. Results Thirty-one patients with gout performed the initial generation of areas of importance. These areas were combined to form 14 items, which were ranked and scored by 107 patients. Four areas were ranked first to third most important by at least 20% of participants. These were pain (median rating, 10), loss of joint motion (median rating, 9), work loss (median rating, 7), and joint inflammation/swelling (median rating, 8). Three additional areas were ranked highly by at least 10% of patients: difficulty with wearing shoes, having to undertake a restrictive diet, and sleep. Conclusions These data largely confirmed the relevance of the gout OMERACT domains while identifying additional issues for patients that require further investigation.

Ongoing reviews of Cochrane collaboration show that there is still very little reliable information based on randomized controlled trials on which to base treatment decisions in acute and chronic gout. Recent studies have stressed that avoidance of factors contributing to development of gouty attacks such as diuretic therapy, weight gain, and alcohol consumption may lead to a decrease in gouty arthritis. Attention to minidose aspirin and its effect on serum uric acid levels was addressed. A low carbohydrate, high protein and unsaturated fat diet was recommended for gouty patients since they all enhance insulin sensitivity and therefore may promote a reduction in serum uric acid levels. Treatment of gout in transplant recipients brings into focus some of the issues regarding management of gout, because gout is a common problem among transplant patients.

The first descriptions of gout can be traced to the dawn of recorded medical history, yet a number of controversies and unanswered questions remain regarding diagnosis and treatment of gout. Questions can still be posed about the need for crystal identification of all cases, the utility of a 24-hour urine collection for uric acid, and even the difficulty of choosing a technique for measurement of uric acid. Some time has elapsed since Mesner stated in 1623, "Love and gout are incurable." How far have we come? How have we evaluated different treatments for gout? Ongoing reviews of the Cochrane collaboration show that there is still very little reliable information based on randomized controlled trials on which to base treatment decisions in acute and chronic gout.

Not all gout presents with involvement of the big toe, and not all gout patients are middle-aged men. Chronic gout may mimic rheumatoid arthritis; hyperuricemia may develop in postmenopausal women and in organ transplant recipients who are being treated with immunosuppressive agents. Both classic and nonclassic cases may benefit from new therapeutic agents.

Roddy and colleagues’ summary of the current management of acute and chronic gout is useful,1 but it omitted to mention the effect that commonly prescribed drugs can have on the incidence of hyperuricaemia and gout. Most patients with gout have cardiovascular comorbidity and will have been prescribed drugs to manage hypertension. Calcium …

Background Although lifestyle interventions are commonly recommended in the management of patients with chronic gout, the evidence from trial data for their benefits and safety has not been previously examined in a systematic review. Objectives The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies on 5 April 2013. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles. Selection criteria Studies were included if they were randomised or quasi-randomised controlled trials (RCTs or CCTs) which compared lifestyle interventions to another therapy (active or placebo) in patients with chronic gout. Outcomes of interest were changes in gout attack frequency, joint pain, serum urate levels, tophus size, function, quality of life and adverse effects. Data collection and analysis Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach. Main results Only one study (120 participants), at moderate risk of bias, was included in the review. Patients were randomised to one of three interventions: either skim milk powder (SMP) enriched with glycomacropeptide (GMP) and G600, non-enriched SMP or lactose powder, over a three-month period. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the three-month study period. Low quality evidence indicated that there was no difference between the SMP/GMP/G600 group and combined control groups (SMP and lactose powder) at three months (mean difference (MD) -0.21, 95% confidence interval (CI) -0.76 to 0.34). There were no significant between-group differences in terms of withdrawals due to adverse effects (risk ratio (RR) 1.27, 95% CI 0.53 to 3.03), and serious adverse events resulting in hospitalisation (2/40 SMP/GMP/G600 group versus 3/80 controls; RR 1.33, 95% CI 0.23 to 7.66). Gastrointestinal adverse effects were the most commonly reported. Pain from self reported gout flares, measured on a 10-point Likert scale, improved more in the SMP/GMP/G600 group compared to controls (MD -1.03, 95% CI -1.96 to -0.10), an absolute difference of 10% (absolute risk difference -0.10, 95% CI -0.20 to -0.01). This is unlikely to be of clinical significance. There was no significant difference in physical function between SMP/GMP/G600 and the control groups at three-month followup (MD -0.03, 95% CI -0.14 to 0.08). Tophus regression and serum urate normalisation were not reported in this study. Authors' conclusions While there is good evidence from observational studies of an association between various lifestyle risk factors and gout development, there is a paucity of high-quality evidence from randomised controlled trials to either support or refute the use of lifestyle modifications for improving outcomes in people with chronic gout.

Background Allopurinol, a xanthine oxidase inhibitor, is considered one of the most effective urate-lowering drugs and is frequently used in the treatment of chronic gout. Objectives To assess the efficacy and safety of allopurinol compared with placebo and other urate-lowering therapies for treating chronic gout. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE on 14 January 2014. We also handsearched the 2011 to 2012 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts, trial registers and regulatory agency drug safety databases. Selection criteria All randomised controlled trials (RCTs) or quasi-randomised controlled clinical trials (CCTs) that compared allopurinol with a placebo or an active therapy in adults with chronic gout. Data collection and analysis We extracted and analysed data using standard methods for Cochrane reviews. The major outcomes of interest were frequency of acute gout attacks, serum urate normalisation, pain, function, tophus regression, study participant withdrawal due to adverse events (AE) and serious adverse events (SAE). We assessed the quality of the body of evidence for these outcomes using the GRADE approach. Main results We included 11 trials (4531 participants) that compared allopurinol (various doses) with placebo (two trials); febuxostat (four trials); benzbromarone (two trials); colchicine (one trial); probenecid (one trial); continuous versus intermittent allopurinol (one trial) and different doses of allopurinol (one trial). Only one trial was at low risk of bias in all domains. We deemed allopurinol versus placebo the main comparison, and allopurinol versus febuxostat and versus benzbromarone as the most clinically relevant active comparisons and restricted reporting to these comparisons here. Moderate-quality evidence from one trial (57 participants) indicated allopurinol 300 mg daily probably does not reduce the rate of gout attacks (2/26 with allopurinol versus 3/25 with placebo; risk ratio (RR) 0.64, 95% confidence interval (CI) 0.12 to 3.52) but increases the proportion of participants achieving a target serum urate over 30 days (25/26 with allopurinol versus 0/25 with placebo, RR 49.11, 95% CI 3.15 to 765.58; number needed to treat for an additional beneficial outcome (NNTB) 1). In two studies (453 participants), there was no significant increase in withdrawals due to AE (6% with allopurinol versus 4% with placebo, RR 1.36, 95% CI 0.61 to 3.08) or SAE (2% with allopurinol versus 1% with placebo, RR 1.93, 95% CI 0.48 to 7.80). One trial reported no difference in pain reduction or tophus regression, but did not report outcome data or measures of variance sufficiently and we could not calculate the differences between groups. Neither trial reported function. Low-quality evidence from three trials (1136 participants) indicated there may be no difference in the incidence of acute gout attacks with allopurinol up to 300 mg daily versus febuxostat 80 mg daily over eight to 24 weeks (21% with allopurinol versus 23% with febuxostat, RR 0.89, 95% CI 0.71 to 1.1); however more participants may achieve target serum urate level (four trials; 2618 participants) with febuxostat 80 mg daily versus allopurinol 300 mg daily (38% with allopurinol versus 70% with febuxostat, RR 0.56, 95% CI 0.48 to 0.65, NNTB with febuxostat 4). Two trials reported no difference in tophus regression between allopurinol and febuxostat over a 28- to 52-week period; but as the trialists did not provide variance, we could not calculate the mean difference between groups. The trials did not report pain reduction or function. Moderate-quality evidence from pooled data from three trials (2555 participants) comparing allopurinol up to 300 mg daily versus febuxostat 80 mg daily indicated no difference in the number of withdrawals due to AE (7% with allopurinol versus 8% with febuxostat, RR 0.89, 95% CI 0.62 to 1.26) or SAE (4% with allopurinol versus 4% with febuxostat, RR 1.13, 95% CI 0.71 to 1.82) over a 24- to 52-week period. Low-quality evidence from one trial (65 participants) indicated there may be no difference in the incidence of acute gout attacks with allopurinol up to 600 mg daily compared with benzbromarone up to 200 mg daily over a four-month period (0/30 with allopurinol versus 1/25 with benzbromarone, RR 0.28, 95% CI 0.01 to 6.58). Based on the pooled results of two trials (102 participants), there was moderate-quality evidence of no probable difference in the proportion of participants achieving a target serum urate level with allopurinol versus benzbromarone (58% with allopurinol versus 74% with benzbromarone, RR 0.79, 95% CI 0.56 to 1.11). Low-quality evidence from two studies indicated there may be no difference in the number of participants who withdrew due to AE with allopurinol versus benzbromarone over a four- to nine-month period (6% with allopurinol versus 7% with benzbromarone, pooled RR 0.80, 95% CI 0.18 to 3.58). There were no SAEs. They did not report tophi regression, pain and function. All other comparisons were supported by small, single studies only, limiting conclusions. Authors' conclusions Our review found low- to moderate-quality evidence indicating similar effects on withdrawals due to AEs and SAEs and incidence of acute gout attacks when allopurinol (100 to 600 mg daily) was compared with placebo, benzbromarone (100 to 200 mg daily) or febuxostat (80 mg daily). There was moderate-quality evidence of little or no difference in the proportion of participants achieving target serum urate when allopurinol was compared with benzbromarone. However, allopurinol seemed more successful than placebo and may be less successful than febuxostat (80 mg daily) in achieving a target serum urate level (6 mg/dL or less; 0.36 mmol/L or less) based on moderate- to low-quality evidence. Single studies reported no difference in pain reduction when allopurinol (300 mg daily) was compared with placebo over 10 days, and no difference in tophus regression when allopurinol (200 to 300 mg daily) was compared with febuxostat (80 mg daily). None of the trials reported on function, health-related quality of life or participant global assessment of treatment success, where further research would be useful.

The aim of this study was to develop and validate a new radiographic damage scoring method (DAmagE index of GoUt; DAEGU) in chronic gout using plain radiography. Two independent observers scored foot x-rays from 15 patients with chronic gout according to the DAEGU method and the modified Sharp/van der Heijde (SvdH) method. The 10 metatarsophalangeal (MTP) and 2 interphalangeal (IP) joints of the first toes of both feet were scored to assess the degrees of erosion and joint space narrowing (JSN). The intraobserver and interobserver reliabilities were analyzed by calculating the intraclass correlation coefficient (ICC) and minimal detectable change (MDC). The correlation between the DAEGU and SvdH methods was analyzed by calculating the Spearman's rho correlation coefficients and Kappa coefficients. The DAEGU method was found to be highly reproducible (0.945–0.987 for the intraobserver and 0.993–0.996 for the interobserver ICC values). The erosion, JSN, and total scores exhibited strong positive correlations between the DAEGU and SvdH methods and also within each method (r = 0.860–0.969, P < 0.001 for all parameters). The DAEGU and SvdH methods were in very good agreement as determined by Kappa coefficient analysis [0.732 (0.387–1.000) for erosion and 1.000 (1.000–1.000) for JSN]. In conclusion, this study revealed that DAEGU method was a reliable and feasible tool in the assessment of radiographic damage in chronic gout. The DAEGU method may provide a more easy assessment of structural damage in chronic gout in the real clinical practice., Graphical Abstract

Advanced imaging modalities including MRI, ultrasound (US), CT and dual energy CT have important applications in gout. While conventional radiography (X-ray) remains the most widely used form of imaging in the clinical setting and is helpful in revealing erosions in chronic gout, these new imaging tools can reveal joint damage and tophi at a much earlier stage. As all are multiplanar techniques, they can define the position and dimensions of tophi, with startling clarity, as well as the size and extent of bone erosions. US and MRI also reveal the severity of inflammation within and adjacent to the joint and can capture information about the composite, vascular nature of many tophaceous deposits. These features can be used as imaging outcome measures, to monitor responses to anti-inflammatory and urate lowering therapies. The new possibility that gout could be diagnosed using imaging, without aspirating the joint, is on the horizon. This review discusses the clinical and research applications of advanced imaging in gout with particular focus on diagnosis and monitoring of joint inflammation and damage.

Gout is a painful inflammatory arthritis with a prevalence of approximately 4% in the United States, affecting an estimated 8.3 million adults. The past 20 years have shown significant increases in the number of patients with gout and its incidence may still be increasing. Current treatment options to control the pain and inflammation of acute gout include nonsteroidal anti-inflammatory drugs, colchicine and corticosteroids, although patients are often unresponsive to, intolerant of, or have contraindications for, these therapies. Additional treatment options are therefore needed for this population with difficult-to-treat gout.Currently available and investigational anti-inflammatory agents for acute and chronic gout will briefly be reviewed. Canakinumab , a fully human monoclonal anti-interleukin (IL)-1β antibody that selectively blocks IL-1β and that is being investigated for the treatment of gout, will be discussed in greater detail.Canakinumab has been found to be superior to triamcinolone acetonide in acute gout and to colchicine in gout attack prophylaxis in reducing pain and risk of new gout attacks. Canakinumab's long half-life contributes to its prolonged anti-inflammatory effects.

Objective: To evaluate efficacy and safety of pegloticase, approved by the Food and Drug Administration in September 2010 for treatment of patients with chronic treatment-refractory gout. Data Sources: Literature searches were conducted using PubMed (1948–January 2012), TOXLINE, international Pharmaceutical Abstracts (1970-January 2012), and Google Scholar using the terms pegloticase, puricase, PEG-uricase, gout, uricase, and Krystexxa. Results were limited to English-language publications. References from selected articles were reviewed to identify additional citations. Study Selection and Data Extraction: Studies evaluating the pharmacology, pharmacokinetics, safety, and efficacy of pegloticase for the treatment of chronic treatment-refractory gout were included. Data Synthesis: Pegloticase represents a novel intravenous treatment option for patients who have chronic gout refractory to other available treatments. Pegloticase is a recombinant uricase and achieves therapeutic effects by catalyzing oxidation of uric acid to allantoin, resulting in decreased uric acid concentrations. Results of published trials demonstrate the ability of pegloticase to maintain uric acid concentrations below 7 mg/dL in patients with chronic gout, Data supporting reduction of gout flares are limited. Pegloticase is well tolerated but associated with gout flares and infusion reactions. Other adverse events include nausea, dizziness, and back pain. During Phase 3 trials, 2 patients in the pegloticase biweekly group and 1 in the monthly group experienced heart failure exacerbation; another patient in the monthly group experienced a nonfatal myocardial infarction. Providers should exercise caution before administering pegloticase to patients with cardiovascular disease. The cost burden and safety profile may limit its use in practice, in addition to limited data available to support decreases in patient-centered outcomes (eg, gouty attacks). Conclusions: Pegloticase is an effective option for patients with symptomatic gout for whom current uric acid-lowering therapies are ineffective or contraindicated.

Objectives The management of gouty arthritis is focused on treating pain and inflammation associated with acute flares and preventing further acute flares and urate crystal deposition. A challenge associated with the successful management of gouty arthritis is an increased risk of acute flares during the first months after initiation of urate-lowering therapy (ULT). This increase in flare frequency can occur regardless of the choice of ULT and is linked to suboptimal patient adherence to ULT. Current treatment recommendations for the use of prophylaxis are limited. There are no definitive recommendations as to which agents should be used or for how long therapy is beneficial after starting ULT. This article aims to improve awareness of the importance of gouty arthritis flare prophylaxis when initiating ULT and to summarize current recommendations and clinical findings related to the efficacy and safety of currently available and investigational new therapies. Methods This review discusses the pathophysiology of acute gouty arthritis flares during initiation of ULT and examines the literature on the use of anti-inflammatory prophylaxis for reduction of these flares. Results It has recently become clear that, even when the patient is asymptomatic, chronic inflammation is often present in patients with chronic gouty arthritis. Chronic anti-inflammatory therapy should therefore be added to chronic ULT. Prophylaxis with colchicine as well as with nonsteroidal anti-inflammatory drugs (NSAIDs) during ULT initiation can reduce the incidence and severity of gouty arthritis flares substantially; however, safety concerns associated with colchicine and NSAIDs may limit their use. Conclusion When colchicine and NSAIDs are contraindicated or poorly tolerated, rilonacept and canakinumab, interleukin-1 inhibitors in trials, may prove to be useful alternatives for flare prevention. (Of note, although both inhibit the IL-1β pathway, rilonacept also binds to IL-1α and IL-1RA, in contrast to canakinumab, which binds selectively to IL-1β.)

The tophus is a characteristic and pathognomonic sign of chronic gout. Before effective drugs were available for the treatment of hyperuricaemia about 50 – 60% of patients with gout developed clinically and radiologically apparent urate crystal deposits. Clinical cutaneous manifestations of chronic gout are now rarely observed. However, the presence of degenerative tissues, as in idiopathic osteoarthritis of the fingers, may predispose to the deposition of urate crystals. We report on a patient with secondary – probably diuretic-induced – hyperuricaemia and gout tophi in Heberden's nodes.

Varon de 49 anos con antecedentes de hiperlipemia e ingesta nolica importante. En mayo de 2004 acude a consulta por referir esde hace 10 anos episodios de monoartritis recurrente de 3 dias e duracion, que afectaba de forma sucesiva bien a rodilla izquierda, arso izquierdo, codo izquierdo o primera metatarsofalangica bilaeral, sin otra sintomatologia acompanante. A la exploracion fisica, resentaba semiologia de derrame en rodilla izquierda con limitaion a la flexion a 90◦ y evidencia de tofos en olecranon izquierdo. En la analitica se objetivo una uricemia de 9,4 mg/dl y GGT 66 U/dl. El resto de los parametros (hemograma, TSH, CPK, Factor eumatoide, HLA B27, anticuerpos antipeptido ciclico citrulinado, nmunoglobulinas, orina y uricosuria de 24 h) fueron normales. Se ealizo radiografia de pie izquierdo (fig. 1) que mostro erosiones arginales de bordes bien delimitados en la cabeza del primer etatarsiano, con aumento de partes blandas adyacente. La radiorafia de rodilla izquierda (fig. 2) presentaba lesiones liticas de ordes bien delimitados en epifisis tibial y cambios degenerativos ncipientes a nivel femorotibial. Se realizo artrocentesis de la rodila izquierda. Con visualizacion de cristales de urato monosodico en l liquido sinovial (LS). El cultivo del LS fue negativo.

Objective.To review a novel approach for constructing composite response criteria for use in chronic gout clinical trials that implements a method of multicriteria decision-making.Methods.Preliminary work with paper patient profiles led to a restricted set of core-set domains that were examined using 1000MindsTM by rheumatologists with an interest in gout, and (separately) by OMERACT registrants prior to OMERACT 10. These results and the 1000Minds approach were discussed during OMERACT 10 to help guide next steps in developing composite response criteria.Results.There were differences in how individual indicators of response were weighted between gout experts and OMERACT registrants. Gout experts placed more weight upon changes in uric acid levels, whereas OMERACT registrants placed more weight upon reducing flares. Discussion highlighted the need for a “pain” domain to be included, for “worsening” to be an additional level within each indicator, for a group process to determine the decision-making within a 1000Minds exercise, and for the value of patient involvement.Conclusion.Although there was not unanimous support for the 1000Minds approach to inform the construction of composite response criteria, there is sufficient interest to justify ongoing development of this methodology and its application to real clinical trial data.

Objective.To summarize evidence for and endorsement of serum urate (SU) as having fulfilled the OMERACT filter as a soluble biomarker in chronic gout at the 2010 Outcome Measures in Rheumatology Meeting (OMERACT 10).Methods.Data were presented to support the use of SU as a soluble biomarker in chronic gout and specifically the ability to utilize it to predict future patient-reported outcomes.Results.SU was accepted as having fulfilled the OMERACT filter by 78% of voters. However, consensus was not obtained regarding its use as a soluble biomarker in chronic gout. Although the majority of the criteria for a soluble biomarker were fulfilled, the key criterion of association of the biomarker with outcomes was not agreed upon. It was agreed that the appropriate choice of endpoint must be linked to its clinical importance to the individual with the disorder and its temporal relationship to the intervention. Appropriate outcomes in chronic gout may therefore include gout flares, reduction in tophi, and patient-reported outcomes.Conclusion.SU is a critical outcome measure. It has the potential to fulfil criteria for a soluble biomarker. Further analyses of existing data from randomized controlled trials will be required to determine whether SU can predict future important outcomes, in particular disability.

Subcutaneous bullae over the finger can prove to be a challenge to diagnosticians and clinicians as it can mimic several other joint-related lesions. Gouty tophus and its diagnosis can be difficult in cases of atypical presentations. This report describes a case of chronic gout presenting as subcutaneous bullae only over palmer surface of hand, including the cytologic and histologic findings. A 41-year-old male presenting with multiple subcutaneous bullous lesions of 1 year duration came to the cytology out patient department for a Tzanck preparation. Aspiration yielded chalky white material. FNA smears revealed abundant granular amorphous material, and slender needle-like crystals with a granulomatous inflammatory reaction. Histopathologic confirmation was done and serum uric acid level was 16mg/dl. Fine needle aspiration cytology (FNAC) is a valuable diagnostic tool for the diagnosis of gouty tophi, even in cases of unusual presentation and the pathologist should be aware of the cytological features.

Objectives To determine whether serum urate (SU) fulfills the Outcome measures in Rheumatology (OMERACT) soluble biomarker criteria. Methods The OMERACT soluble biomarker criteria were adapted for use in chronic gout. Potential outcome measures for use in chronic gout were identified. The literature was reviewed to determine which of the potential outcome measures were appropriate and whether there was evidence within the current literature to fulfill the OMERACT biomarker criteria. Results The assay for measurement of SU is reliable, internationally standardized, and readily accessible for use in clinical practice. The effects of sources of variability, including age, sex, ethnicity, circadian rhythms, body mass index, renal/hepatic function, and fasting, are well documented. Tophus regression was identified as appropriate structural outcome measure; however, given that not all patients have clinically apparent tophi, the number of gout flares is also identified as a key outcome measure. Conclusions Serum urate fulfills all the OMERACT biomarker criteria with the exception of its effects on outcome measures. Further analysis of existing and new data sets to determine whether a reduction in SU predicts a reduction in gout flares, the number/size of tophi, and patient reported outcomes using validated measures for these outcomes are required.

Aim: The aim of this study was to ascertain the management of gout by doctors in Malaysia. Methods: A cross-sectional questionnaire survey was carried out among doctors attending rheumatology post-graduate courses, where gout was not a lecture topic. Results: A total of 128 questionnaires were analyzed, of which the majority (67: 52.3%) were general practitioners. In the treatment of acute gout, 68.0% use non-selective non-steroidal anti-inflammatory drugs (NSAIDs), 53.9% use selective COX-2 inhibitors (coxibs), 66.4% use colchicine and 10.2% use allopurinol (ALLO). In the treatment of chronic gout, 36.7% use NSAIDs, 44.5% use coxibs, 19.5% use colchicine and 93% use ALLO. In both acute and chronic gout, corticosteroids (CS) are not used by over 90% of respondents. Fifty percent would stop ALLO during an acute attack. 95.3% do not start ALLO during an acute attack; 87.5% would start ALLO after the attack, with a median of 14 days afterwards. Once ALLO was started, 54.7% would continue indefinitely. Regarding target urate levels while on treatment, 10.9% would be satisfied with a high normal range, 21.9% middle of the range, 18.0% low normal range and 45.3% anywhere within the normal range. Fifteen percent would treat asymptomatic hyperuricemia. Conclusions: In Malaysia, anti-inflammatory agents are most commonly used for the treatment of acute and chronic gout, with corticosteroid usage at a low level. However, there are areas of concern regarding the diagnosis of gout and the usage of ALLO which are not consistent with current guidelines.

Although an ancient disease, gout has been managed mostly based on empirical knowledge. Recently, there has been increased interest in evidence‐based outcomes for both acute and chronic gout. In th...

Introduction. Gout is a chronic painful inflammatory arthritis. The authors interviewed patients with chronic stable gout to assess their hypothetical willingness to pay (WTP) to be cured of their gout. Patients and Methods. Patients with gout were asked how much money they would be willing to pay every month out of pocket or as a co-pay to cure their gout. To assess determinants of WTP amounts, the authors performed stepwise multivariable linear regression analysis, controlling for demographics, health status, and relative concern about gout. Results. Of the 78 patients, 70 (90%) were male, 54 (69%) were Caucasian, 21 (27%) were African American, and 32 (41%) had annual incomes < $25,000. The median WTP amount was $25 ($0, $75) per month, and the mean (s ) was $52 ($74) per month (range, $0-$350); 23 (30%) patients were unwilling to pay any amount. Patients who rated their gout as their top health concern were willing to pay a median of $63 ($25, $100) per month. In multivariable analysis, gout as the top health concern, greater frequency of gouty attacks over the past 1 y, and younger age were significantly associated with WTP amounts (R2 =0:19 ). Conclusion. Many patients with chronic gout would be willing to pay money every month in perpetuity to be cured of their gout. Younger patients, patients whose main health concern is gout, and patients with frequent attacks are willing to pay the most.

Gout is a chronic painful inflammatory arthritis. Data regarding the impact of gout on health-related quality of life, however, are limited.We interviewed patients with chronic stable gout. Health status was measured by using the Short Form 36 (SF-36) physical component summary (PCS) and physical component summary (MCS) and the Health Assessment Questionnaire-Disability Index (HAQ-DI). Direct preference-based measures included a health rating scale (RS), the time tradeoff (TTO), and standard gamble (SG) for one's current health state with gout and current health state without gout; indirect preference-based measures included the SF-6D and the EQ-5D. Disutilities for gout were assessed by subtracting preference scores for current health states with gout from those for current health without gout and were compared between patients ranking gout as their top health concern versus the rest of the patients.Of the 80 interviewees, 72 (90%) were male, 55 (69%) were Caucasian, and the mean (SD) age was 60 (11) years. The mean SF-36 PCS and MCS scores were 38.9 and 48.6, respectively. The mean (SD) SF-6D score was 0.68 (0.13) and the mean (SD) EQ-5D score was 0.73 (0.23). The mean (SD) RS disutility for gout was 0.05 (0.12), the mean TTO disutility was 0.03 (0.12), and the mean SG disutility was 0.02 (0.11). The RS disutilities of subject patients who ranked gout as their top concern (n = 17) trended towards being statistically significantly larger than those of the remaining patients, P = 0.06 but their TTO and SG disutilities were similar to those of the remaining patients.Although physical functioning of patients with gout is often compromised, patients with chronic stable gout do not assign a large disutility to gout per se. Still, patients who rank their gout as their top health concern tend to assign greater RS disutility to gout than do other patients.

Background The evaluation of radiographic damage in inflammatory arthritis has been considered important, because structural damage of affected joints impairs the functional status of patients with various inflammatory rheumatic diseases and increases their economic problems and mortality [1, 2]. However, there has still been no relevant radiographic index for damage of affected joints in patients with chronic gouty arthritis. Modified SvdH scoring method has been proposed to be an alternative method [3], however, it seems to be so complex and also lack of relevance to use in clinical practice. Objectives The aim of this study was to develop and validate more a simple method to score radiographic damage measurement in patients with chronic gout. Methods Two independent observers read foot x-rays using the DAmagE index of GoUt score method (DAEGU score) and the modified Sharp/van der Heijde (SvdH) method. The 10 metatarsophalangeal (MTP) and 2 interphalangeal (IP) joints of the first toes of both feet from 15 patients with chronic gout were scored on plain radiography for erosion and joint space narrowing (JSN) (180 total joints). The intraobserver and interobserver reliability were analyzed by intraclass correlation coefficient (ICC) and minimal detectable change (MDC). The correlation between the DAEGU and SvdH methods was analyzed using Spearman9s correlation coefficients and Kappa coefficients. Results The intraobserver and interobserver ICCs for the DAEGU method were 0.945–0.987 and 0.993–0.996, respectively. The MDC at the 95% confidence interval (MDC95) showed 0.5–2.1 and 0.3–0.7 in the intra- and interobserver analyses, respectively. Strong positive correlations were represented between the DAEGU and SvdH methods for each radiological abnormality including erosion, JSN, and total score (correlation coefficients: r =0.870–0.985, p Conclusions This study demonstrated that the DAEGU score had a high reproducibility and strongly correlated with SvdH. The DAEGU method may provide a more easy assessment of structural damage in patients with chronic gout. References Kavanaugh A, et al. J Rheumatol 2004;31:849–55. Gladman DD, et al. Arthritis Rheum 1998;41:1103–10. Dalbeth N, et al. Arthritis Rheum 2007;57:1067-73. Disclosure of Interest None declared

Streptococcus iniae , a widely distributed fish pathogen, is known to cause rare cases of human infection. We describe 2 cases of invasive S. iniae infection, one with septic arthritis complicating chronic gout and the other with bacteremic cellulitis. Both patients were Chinese and have been regularly handling fresh fish for cooking. Both isolates were unidentified or misidentified by 3 commercially available identification system and were only identified by 16S rRNA gene sequencing. When compared with a clinical isolate of S. iniae from Canada, their colonies were larger, more β-hemolytic, and mucoid. Although bacteremic cellulitis has been described as the most common infection associated with S. iniae , the bacterium has not been reported to cause exacerbations of gouty arthritis previously. Clinical laboratories should be aware of the possibility of different colony morphology of S. iniae from Asia. More accurate identification of nongroupable β-hemolytic streptococci, especially from patients with epidemiologic linkage to fresh fish, may uncover more cases of S. iniae infection. The Asian population and handlers of fresh fish should be informed of the risk of acquiring S. iniae infection.

La gota es una enfermedad con una etiopatogenia clara, diagnóstico preciso y tratamiento eficaz. A pesar de ello, un porcentaje no despreciable de pacientes desarrollan gota tofácea crónica. Su presencia se correlaciona con el tiempo de evolución de la enfermedad y con el grado de elevación de los niveles de ácido úrico. Realizando desde nuestro ámbito un diagnóstico precoz y un tratamiento adecuado conseguiremos disminuir los ataques agudos, prevenir la artropatía crónica y reducir las complicaciones extraarticulares de los pacientes con hiperuricemia.

Gouty arthritis rarely involves anphiartrodial joints such as the manubriosternal joint. We report a case of recurrent manubriosternal joint (MSJ) pain in a patient with idiopathic, tophaceous chronic gouty arthritis. A 52 year old man consulted for recurrent swelling of ankles, wrists, knees, and feet during the previous 12 years. His family doctor had previously made a diagnosis of gout, and intermitent colchicine and allopurinol 100 mg/day were prescribed. Despite treatment, however, he experience esisodes of gout three to four times a year and he stopped treatment. Alcohol intake was about 100 g/day. During the previous two years he was admitted twice to the emergency unit for intense, acute, anterior thoracic pain located on the sternum that lasted two or three days and was ameliorated by analgesics. Electrocardiograms and chest roentgenograms were reported to be …

Objectives To compare functional limitations in patients with chronic gout and matched patients with rheumatoid arthritis (RA) as measured with the HAQ-DI and PF-10. Methods Consecutive patients with crystal deposition proven gout (n=102) or with RA (n=619) visiting the outpatient rheumatology clinic of the hospital in Enschede, the Netherlands completed the HAQ-DI and PF-10. Gout patients were matched to patients with RA on sex, age (± 5 years) and disease duration (±5 years). Ninety-three patients with gout could be successfully matched to 93 patients with RA. The HAQ-DI contains 20 items measuring physical disabilities over the past week in eight categories of daily living. Items are scored on a 4-point rating scale from 0 (without any difficulty) to 3 (unable to do). A total score is calculated by averaging the highest score in each category if at least six categories are completed. The PF-10 is the physical functioning scale of the multidimensional SF-36v2. It measures current limitations in a variety of physical activities using 10 items. Items are scored from 1 (yes, limited a lot) to 3 (no, not limited at all). Scores on the PF-10 items are summed and linearly transformed to range between 0 and 100, with higher scores indicating better functioning. Results In both disease groups mean age was 59 (± 12) years, mean disease duration was 7 (±9) years and 86% of patients were male. Median PF-10 scores did not significantly differ between patients with gout or with RA and ceiling effects (no limitations) were similar (6.7% versus 6.5%) (see table). However, patients with RA had significantly worse HAQ-DI total scores than patients with gout, and ceiling effects were significantly lower in RA than in gout. Analysis of HAQ-DI category scores showed that gout patients had less limitations in activities that involve the upper extremities such as Dressing, Eating, Hygiene and Grip than RA patients, while scores for activities mostly involving the lower extremities were similar. Image/graph: Conclusions Gout patients have less functional limitations than RA patients according to HAQ-DI total scores, while according to PF-10 scores gout patients and RA patients do not significantly differ in functional limitations. HAQ-DI seems to underestimate the functional limitations of gout patients compared to RA patients because of the inclusion of activities involving upper extremities, which may be less relevant for patients with gout. On the other hand PF-10 seems to underestimate the functional limitation of patients with RA because of the emphasis on activities involving lower extremities. Disclosure of Interest None Declared

Gout is a chronic metabolic and inflammatory disease whose sine qua non is hyperuricemia. The acute attacks seen in gout are merely the “tip of the iceberg” and represent the effector response to a set of conditions that lead to monosodium urate precipitation and deposition. Moreover, the chronic state of gout is accompanied by co-morbidities that are not resolved when the inflammatory attacks are treated. In consequence, gout must be thought of as a chronic rather than an intermittent condition, and gout treatment should be considered a long-term, and possibly lifelong endeavor. In this brief talk we will consider the chronic nature of gout, as well as current recommendations for chronic gout treatment (diet, lifestyle, and anti-inflammatory and urate-lowering pharmacotherapy), and for assessment of treatment outcomes, including the potential use of imaging. We will also discuss the possibility that good gout treatment initially results in easier gout treatment later on (“debulking”, or Perez-Ruiz’s “dirty dish” hypothesis), and the question of whether “tight control” of gout may have benefit not only for gout, but for gout’s co-morbidities as well. Disclosure of Interest M. Pillinger Grant/research support from: Savient Pharmaceuticals, Takeda Pharmaceuticals

Background Gouty arthritis-causing uric acid is persistently in excess in the form of tophi. The ultimate therapeutic ideal should be to completely eliminate all tophi. So far, clinicians have relied on physical examination and plain radiographs to assess the locations and sizes of Gouty tophi. The dual energy computerized tomography (DECT), magnetic resonance imaging (MRI), 2-fluoro-deoxy-D-glucose (FDG) positron emission tomography (PET) each offers a different perspective of gouty tophi. None of the papers have used all four techniques concomitantly, no guidelines are available concerning their applications. Objectives To visualize in a gout patient,using four different imaging techniques,the locations, sizes, compactness of tophi. Methods The feet and knees were imaged by X-ray, MRI, DECT and PET. Results DECT uncovered deposits in unexpected locations. The combination of DECT, MRI and PET showed that tophi were much larger and more inflammatory than clinically suspected. Conclusions The locations and sizes of tophi in chronic gout patients can far exceed those accessible by physical examination and X-ray. These can be critical when making decisions concerning the initiation and aggressiveness of serum uric acid- lowering therapies. References Neogi T. Clinical practice. Gout. N Engl J Med. 2011 Feb 3;364(5):443-52. Dalbeth N, McQueen FM. Use of imaging to evaluate gout and other crystal deposition disorders. Curr Opin Rheumatol. 2009 Mar;21(2):124-31. Choi HK, Al-Arfaj AM, Eftekhari A, Munk PL, Shojania K, Reid G, et al. Dual energy computed tomography in tophaceous gout. Ann Rheum Dis. 2009 Oct;68(10):1609-12. Nicolaou S, Yong-Hing CJ, Galea-Soler S, Hou DJ, Louis L, Munk P. Dual-energy CT as a potential new diagnostic tool in the management of gout in the acute setting. AJR Am J Roentgenol. 2010 Apr;194(4):1072-8. Ko KH, Hsu YC, Lee HS, Lee CH, Huang GS. Tophaceous gout of the knee: revisiting MRI patterns in 30 patients. J Clin Rheumatol. 2010 Aug;16(5):209-14. Disclosure of Interest None Declared

Background The Medical Outcomes Study Short-Form 36 (SF-36) has been endorsed as a valid instrument for measurement of health related quality of life (HRQoL) in gout at the International Consensus Conference on Outcome Measures in Rheumatology (OMERACT 9) [1] Objectives To compare HRQoL in patients with chronic gout and matched patients with rheumatoid arthritis (RA) as measured with the SF-36 version 2 (SF-36v2). Methods Consecutive patients with crystal deposition proven gout (n=102) or with RA (n=619) visiting the outpatient rheumatology clinic of the hospital in Enschede, the Netherlands completed the SF-36v2. Gout patients were matched to patients with RA on sex, age (± 5 years) and disease duration (±5 years). Ninety-three patients with gout could be successfully matched to 93 patients with RA. SF-36v2 measures eight aspects of HRQoL with a total of 36 items (Physical Functioning (PF), Role problems as a result of physical health (RP), Bodily Pain (BP), General health (GH), Vitality (VT), Social Functioning (SF), Mental Health (MH) and Role problems as a result of emotional problems (RE)), as well as two summary scores for physical health (Physical Component Summary, PCS) and mental health (Mental Component Summary, MCS). Differences in the eight aspects and two summary scores of HRQoL between patients with gout and RA were tested by t-tests. Results In both disease groups mean age was 59 (± 12) years, mean disease duration was 7 (±9) years and 86% of patients were male. HRQoL scores in matched groups of patients with gout and RA were highly similar (see table). Mean differences between patients with gout and RA were small and non-significant for all scales and both summary scores. Image/graph: Conclusions As measured with SF36, the impact of chronic gout is highly similar to the impact of RA on health related quality of life. References Grainger R, Taylor JW, Dalbeth N et al. Progress in Measurement Instruments for Acute and Chronic Gout Studies. J Rheumatol 2009; 36:2346–55 Disclosure of Interest None Declared

Background Urate-lowering therapy (uric acid Objectives To comparerecurrent gout attacks in chronic gout treated by US findings normalization strategy or ULT strategy. Methods We designed an open label, randomized controlled trial. We screened 74 chronic gout (uric acid>7.0 mg /ld., and double contour sign of US findings in any joint) for inclusion. 63 gout patients were randomly allocated either US strategy group (US group) or ULT group(C group). In both strategies febuxostat is used. US strategy is performed US by 4 weeks. Double contour sign or urate crystals were evaluated; febuxostat is intensified to dissolve it. ULT strategy is performed blood examination by 4 weeks. Febuxostat is intensified to target uric acid Results The characteristics of each group at baseline were not significantly different. There was no significant difference in the proportion of no recurrent attack within 52 weeks between the US strategy (87.6%) and ULT strategy (83.4%) groups. There was no significant difference in the occurrence of adverse events (AEs) between the US strategy and ULT strategy groups. Conclusions In chronic gout, if the patients were treated by febuxostat, US without blood examination might be equivalent to uric acid in blood. References A systematic review of ultrasonography in gout and asymptomatic hyperuricaemia. Chowalloor PV, et al. Ann Rheum Dis. 2013 Jan 3. [Epub ahead of print]2. EULAR evidence based recommendations for gout . Part II:Management. Report of a task force of the EULAR Standing Committee For International Clinical Studies Including Therapeutics (ESCISIT). Zhang W, et al. Ann Rheum Dis. 2006 Oct;65(10):1312-24. Epub 2006 May 17.3. Efficacy and Tolerability of Febuxostat in Hyperuricemic Patients With or Without Gout : A Systematic Review and Meta-Analysis. Ye P, et al. Clin Ther. 2013 Jan 15. doi:pii: S0149-2918(12)00723-0. 10.1016/j.clinthera.2012.12.011. Disclosure of Interest : None Declared

To the Editor: We thank Drs. Dalbeth and McQueen for their kind comments1 on our recent article on radiographic bone damage between chronic gout and inflammatory cytokines2. We assessed radiographic damage of the involved foot joints in patients with chronic gout according to the modified Sharp/van der Heijde … Address correspondence to Dr. S-K. Kim, Department of Internal Medicine, Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, 3056-6 Daemyung 4-Dong, Namgu, Daegu 705-718, Republic of Korea. E-mail: kimsk714{at}cu.ac.kr

A case of tophaceous gout involving a foot sesamoid is described in a middle-aged man with a history of chronic gout. Microscopic findings consisting of tophaceous foci located beneath an intact hyaline articulating surface are correlated with associated radiographs. (J Am Podiatr Med Assoc 91(7): 379-380, 2001)