Gout Urate Cryst. Depos. Dis., Volume 3, Issue 1 (March 2025) – 3 articles

Gout management strategies remain a topic of debate, particularly regarding the efficacy of treat-to-target (T2T) and treat-to-avoid-symptoms (T2S) approaches. T2T, endorsed by major rheumatology societies, involves systematic serum urate (sUA) monitoring and urate-lowering therapy (ULT) dose escalation to maintain sUA below a predefined threshold. In contrast, T2S, which focuses on symptom relief rather than routine sUA monitoring, is supported by alternative guidelines. Despite the widespread adoption of T2T in other chronic diseases, its clinical benefits beyond biochemical parameters, such as serum urate reduction, remain uncertain in gout. This study evaluates current evidence on T2T and T2S, analyzing data from a pragmatic multicenter trial comparing both strategies. Findings suggest that while T2T is effective in reducing sUA levels, its superiority in preventing flares and improving patient-reported outcomes remains inconclusive. Some studies report reduced tophus burden and better adherence with T2T, whereas others find negligible differences in pain relief and functional improvement between the two strategies. The lack of high-quality comparative trials underscores the need for further investigation. Future research should prioritize long-term, patient-centered outcomes and pragmatic implementation strategies. Full article

Lifelong urate-lowering therapy (ULT) is recommended for gout to prevent flares and urate deposition. However, concerns about its adherence, long-term side effects, and the necessity of continuous treatment after achieving remission raise critical questions. Two randomised controlled trials (RCTs), GO TEST Finale and STING, aim to evaluate the safety and feasibility of ULT discontinuation in gout patients in remission. The GO TEST Finale is a superiority trial involving 310 patients in the Netherlands, comparing a treat-to-target (T2T) ULT continuation strategy with ULT discontinuation. Patients in the discontinuation arm resume ULT only after flare recurrence or tophi development. The primary outcomes focus on remission criteria failure over 24 months, while the secondary outcomes explore predictors of successful discontinuation and cost-effectiveness. The STING study, a non-inferiority trial in France, includes 450 patients without ultrasound (US) evidence of urate deposits. Patients in the discontinuation group resume ULT if a US detects urate deposition during follow-up, minimising flare risk. The primary outcomes measure the proportion of patients experiencing flares at two years, with the secondary outcomes examining the long-term health impacts and cost-effectiveness. These trials provide an opportunity for translational research into the immunological and epigenetic effects of rising serum urate levels. The results could inform personalised strategies for a drug-free period and address the critical question of whether lifelong ULT is necessary for gout management. The complementary findings from both trials are expected to contribute significantly to resolving this ongoing clinical debate. Full article

Gout is a common inflammatory joint disease in China. In recent years, the prevalence of gout in China has been increasing and the onset age of gout has been trending younger. The common risk factors for gout in China include hyperuricemia, age, sex, obesity, hypertension, metabolic syndrome, use of drugs (e.g., diuretics), dietary factors, chronic kidney disease (CKD), ethnicity, and income. Chinese clinical guidelines recommend the diagnosis of subclinical gout, refractory gout, and clinical classification of hyperuricemia in gout patients with early-onset or family history. Maintaining a consistently low level of serum urate is crucial for the effective long-term treatment of gout. However, the Chinese guidelines recommend paying special attention to allopurinol hypersensitivity when considering urate-lowering drugs. The adherence rate to urate-lowering therapy (ULT) in Chinese patients with gout ranges from 9.6% to 40.7%. Patient education and reducing drug side effects are effective approaches to improve the adherence to ULT and the rate of achieving the target urate level. The development of new treatment principles based on clinical trials, such as ULT based on the classification of hyperuricemia and urine alkalization, is recommended to improve patient outcomes and reduce potential side effects. The study of genetics, metabolites, and intestinal microbiota has yielded new findings that may aid in the diagnosis, classification, and pathogenesis of gout in China. Full article