Annals On Call - The Gout Wars: When Guidelines Collide
Authors: Robert M. Centor, Robert M. McLean
Journal: Annals of Internal Medicine (2018)

Web Exclusives7 August 2018Annals On Call - The Gout Wars: When Guidelines CollideFREERobert M. Centor, MD and Robert M. McLean, MDRobert M. Centor, MDHuntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Search for more papers by this author and Robert M. McLean, MDYale School of Medicine, Yale-New Haven Hospital, and Yale-New Haven Health System, New Haven, Connecticut (R.M.M.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/A18-0001 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In this episode of Annals On Call, Dr. Centor discusses targeting treatment for gout with Dr. Robert McLean, a rheumatologist and a co-author of the American College of Physicians clinical guidelines on the management of gout.Annals articles discussed include...Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians: http://annals.org/aim/fullarticle/2578528/management-acute-recurrent-gout-clinical-practice-guideline-from-american-collegeManagement of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline: http://annals.org/aim/fullarticle/2578526/management-gout-systematic-review-support-american-college-physicians-clinical-practiceThe Long and Winding Road to Clinical Guidelines on the Diagnosis and Management of Gout: http://annals.org/aim/fullarticle/2578454/long-winding-road-clinical-guidelines-diagnosis-management-goutAbout Annals On CallAnnals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery.For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall. Comments0 CommentsSign In to Submit A Comment Burton AbramsNo institutional affiliation7 August 2018 Gout treatment I just finished listening to the Annals on Call podcast with Dr. Robert McLean about the differences in ACP vs. ACR recommendations for the treatment of gout. Both the ACP and ACR are missing a big underlying cause of gout which would greatly affect its effective treatment. One aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham wrote about it in 1683. A recent study by Dr. Hyon Choi et al confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not.Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. Although Kelley's Textbook of Rheumatology lists respiratory insufficiency as a cause of acidosis leading to hyperuricemia, the hypoxemia of sleep apnea actually has three effects which can lead to an overnight gout flare in short order. Effect #1 is cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the transient cellular generation of excess uric acid fed into the blood, faster than any food would cause. Effect #2 is transient hypercapnia and acidosis, so that the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there is an abrupt increase in the influx of uric acid in the blood, slowed efflux, and abruptly reduced storage capacity -- perfect storm conditions for monosodium urate precipitation. Furthermore, after awakening and normal breathing is restored, the first two effects dissipate so that a blood test taken during waking hours misses their peaks. And if monosodium urate has precipitated recently, then the measurement of serum uric acid is greatly undervalued.Gout has been reported to have so many of the same comorbidities already known to be consequences of long-term untreated sleep apnea (eg., cardiovascular diseases, diabetes, kidney disease, hypertension.) Recent studies have found that increasing the dosage of urate lowering drugs had no benefit for reducing major cardiovascular events or all-cause mortality in gout patients. One of the first steps for treating gout should be screening and diagnosis for sleep apnea, followed by treatment of the sleep apnea where indicated. I know from my own experience and the experiences of others that overcoming sleep apnea can prevent additional inflammatory gout flares immediately and completely. Effects #1 and #2 don't occur, and Effect #3 may reverse over following effective treatment for sleep apnea. More importantly, gout is an early warning of sleep apnea, which when heeded can lead to the early treatment of sleep apnea, thereby greatly reducing the risk for the development of sleep apnea's later developing life-threatening consequences. Overcoming the sleep apnea can save lives as well as save joints. Author, Article, and Disclosure InformationAffiliations: Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Yale School of Medicine, Yale-New Haven Hospital, and Yale-New Haven Health System, New Haven, Connecticut (R.M.M.)Disclosures: Dr. Centor has disclosed the following: Honoraria: Medscape. Dr. McLean has disclosed relationships with the following organizations: Takeda Pharmaceuticals (speakers bureau), ABIM (board member), Northeast Medical Group of Yale New Haven Health System (employment), and American College of Rheumatology (member of Quality of Care Committee; current appointment ends November 2018).Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoManagement of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians Amir Qaseem , Russell P. Harris , Mary Ann Forciea , and Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline Paul G. Shekelle , Sydne J. Newberry , John D. FitzGerald , Aneesa Motala , Claire E. O'Hanlon , Abdul Tariq , Adeyemi Okunogbe , Dan Han , and Roberta Shanman The Long and Winding Road to Clinical Guidelines on the Diagnosis and Management of Gout Robert M. McLean The Gout Wars Burton Abrams Metrics Cited byThe Gout WarsBurton Abrams, MS 7 August 2018Volume 169, Issue 3Page: OC1KeywordsDiagnostic techniquesDisclosureGoutHealth careHealth care qualityPatientsRheumatologySystematic reviewsTreatment guidelines ePublished: 7 August 2018 Issue Published: 7 August 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...