Conventional oral urate-lowering therapies frequently to fail to achieve target serum uric acid (sUA) levels in patients with chronic kidney disease and uncontrolled refractory gout. This can lead to increased urate burden and complications, including worsening kidney disease, cardiovascular events, and metabolic syndrome. Tune in to find out how to incorporate targeted therapies when managing uncontrolled refractory gout and improve your patients’ quality of life.
Treat or Refer: Who Is Responsible for Managing Gout?
Treat or Refer: Who Is Responsible for Managing Gout?
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Hello. This is CME on ReachMD, and I’m Dr. John Botson from Anchorage, Alaska. I’m here today with Dr. Abdul Abdellatif, a nephrologist who’s going to speak with us some about the nephrology perspectives of gout.
Dr. Abdellatif, do you feel, in your clinic, responsible for managing these patients with gout as a nephrologist versus me as a rheumatologist?
We have recently, in the past 15 years, shifted the focus that this is really our disease. And the reason I say that is because the kidney’s really the main organ that gets the responsibility to eliminate the uric acid from the body. And we know that as the patient’s kidney function decreases, either with age or development of chronic kidney disease or other factors related to medications, that the uric acid starts to build up, and those patients who have gout have actually worsening episodes of recurrent gout attacks because of the burden of the uric acid.
Uric acid is not part of the routine chemistry that’s ordered in a kidney clinic, but now we actually need to order that test. Number one, to diagnose our patients at an early stage so we can control their disease. Secondary, because we know that gout itself, as it progresses, it can lead to progression of kidney disease in some of the patients at risk.
Now it is important to actually get the patient to a nephrologist sooner than later because most of the patients don’t even express their symptoms when they go see the primary care physicians and may self-treat. But unfortunately, some of those medications that the patient may reach for to treat themselves include NSAIDs [nonsteroidal anti-inflammatory drugs] over the counter, and those are toxic to the kidney. We really encourage the primary care physicians, podiatrists, even orthopedic surgeons to actually refer the patients for early evaluation as soon as they’re diagnosed with the disease. They do not have to have chronic kidney disease before we see them because our goal is to actually slow down the progression of this chronic disease.
I appreciate that perspective. You know, as a rheumatologist, one of the things that we kind of talk about with our nephrology colleagues is at what point do you check or ask the patient if they have joint pain, which essentially is what separates hyperuricemia from gout is the patient that actually has an active inflammatory process going on in the joints. Rheumatologists, we kind of look at that right up front with the patients coming in the door, but maybe I’ve heard the critique that the nephrologists maybe don’t feel comfortable with that? Is that something that maybe needs to change?
I believe so because, you know, patients with chronic kidney disease are considered the most complex, probably the most ill, chronic patients that we see in clinics in general. And because they have so many other comorbidities – the nephrologist may be trying to control the blood pressure, they’re trying to control their volume status, electrolyte abnormalities, may have to be participating in controlling their heart failure and even diabetes nowadays – that gout may be the last thing on their mind when the patient comes into their practice.
We do sometimes get patients that have been on either NSAIDs for a long time or colchicine for a long time or maybe are receiving a lot of courses of steroid therapy for a long time before they’re even put on the appropriate therapy to lower their uric acid. They’re not even on urate-lowering agents. And it’s really important to not only put them on the appropriate urate-lowering agents, but also escalating the dose to the appropriate target to make sure their gout is controlled and eventually, if they are not controlled, that there we do have even further options for these patients that include infusion therapies.
The bottom line of this is that no one of us, rheumatology or nephrology, is going to be able to manage these patients by themselves. And it’s important, I guess, that we keep talking and making sure we’re taking the best care of these patients that we can.
So I think that’s it for this discussion. Thanks for everyone out there listening and hope to see you again.
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In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Richard Johnson, MD
Professor of Medicine
University of Colorado
Anschutz Medical Campus
Research: National Institute of Health
Ownership Interest: Colorado Research Partners, XORTX Therapeutics
Receives Royalties: Elsevier, BenBella Books
Consulting Fees: Dinora, Horizon Pharma
Abdul A. Abdellatif, MD, FASN
Division of Nephrology
Baylor College of Medicine and CLS Health
No relevant relationships reported
John K. Botson, MD, RPh
Director of Rheumatology
Orthopedic Physicians Alaska
Research: Horizon Therapeutics
Patent Holder: Horizon Therapeutics
Consulting Fee: AbbVie, Amgen, Eli Lilly, Horizon Therapeutics, Novartis
Brittany Weber, MD, PhD
Director, Cardio-Rheumatology Clinic
Associate Physician, Prevention Cardiology & Cardiovascular Imaging
Brigham and Women’s Hospital
Research: AHA, NIH
Consulting Fees:, Agepha, Horizon Therapeutics, Kiniksa, Novo Nordisk
- Cindy Davidson has nothing to disclose.
- Hany Ibrahim, MD, has nothing to disclose.
- Samantha Keehn has nothing to disclose.
- John Maeglin has nothing to disclose.
- Brian McDonough has nothing to disclose.
- Tim Person has nothing to disclose.
After participating in this educational activity, participants should be better able to:
- Discuss the pathophysiology and prevalence of high uric acid levels and uncontrolled gout in patients with renal disease and the contribution of chronic gout to chronic kidney disease (CKD) progression, associated comorbidities, and increased mortality
- Apply knowledge of available diagnostic tools to identify patients with elevated serum uric acid (sUA) levels early in the progression of CKD to initiate proper urate-lowering therapy (ULT) and reduce urate burden
- Summarize the limitations of standard ULT options in patients with CKD
- Incorporate emerging urate-lowering therapies, including pegloticase-methotrexate combined therapy and clinical trial evidence, into clinical practice in the treatment of appropriate patients with uncontrolled gout
- Discuss gout as an independent risk factor for CVD and its association with CVD morbidity and mortality, necessitating early screening and treatment to attain target sUA levels
This activity is designed to meet the educational needs of nephrologists, rheumatologists, cardiologists, primary care physicians, and others who encounter, diagnose, and treat gout.
In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Global Learning Collaborative (GLC) designates this activity for 1.0 nursing contact hour. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
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This activity is supported by an independent educational grant from Horizon Therapeutics, USA, Inc.
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