Treating to target in gout: absence of evidence

I understand that my title alone is considered infurating to rheumatologists. Hear me out.

My interest in gout targets was peaked this summer when I encountered this article from the Journal of Rheumatology. Its results showed that 55% of long-term gout patients had their uric acid checked in the past 5 years, and the uric acid was at target in 22% of patients.

The study’s conclusion? “Gout is managed poorly in Australian primary care”. Wait, what? Where are the outcome measures? Making conclusions based on a surrogate marker? This surrogate marker better be good….

Most papers which discuss treating to target in gout simply reference the EULAR task force and the British Society of Rheumatology guidelines, but we need to dig a bit deeper.

There’s no doubt that there appears to be a correlation between lower uric acid levels and lower rates of flares. But what about prospective trials of treating to target <360 compared to a higher target, or compared to treating to outcome? Not a single trial exists. The target they have chosen was based on initial basic science dissolution studies, but that is miles away from the prospective evidence needed to justify militantly recommending specific targets.

A good analogy to the uric acid story is treating LDL with statins. We know that 80mg of simvastatin does provide a small, but measurable decrease in cardiovascular events compared to 10mg of simvastatin. Does every patient need to be on a higher dose of statin to achieve an LDL target? We have no prospective evidence to support treating to LDL targets, and after years of debate, we are finally moving away from LDL targets in cardiovascular risk management. The same argument can be made with uric acid targets. Does treating with higher doses of allopurinol decrease risk of flares more than lower doses? Likely yes. But will lower doses of allopurinol likely suffice for the majority of patients, regardless of uric acid level? Also likely yes.

I hope we can move in the same direction with gout management that we have with lipids. Treat to outcomes, and intensify treatment should patients continue to flare on lower doses. Stop being a slave to uric targets that don’t have a solid evidence base.

 

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