Welcome to GoutCaster

From The Editor

After just one month, your usual editor, Uri Khassid, has succumbed to a bout of gout he can do nowt about. I hope he recovers soon.

GoutPal has asked me to stand in for him. I'm particularly honored as this edition is dedicated to preparing you for my special year - (2)007.

This month's issue includes:

Gout Treatment Research

News from the American College of Rheumatology following their annual meeting

Competition.

Winner of the first (and last) competition rewarding senders of messages to GoutPal.

Recent GoutPal Changes.

New entertainment section.

Coming soon on GoutPal.

Planned changes to the GoutPal website as we move into (2)007.

If you are reading the text only version of this newsletter, some formatting may look slightly strange. By the time you read this, the HTML version should be online at:
http://www.goutpal.com/GoutCaster-007-gout-james-gout.html

I'd just like to finish by wishing you all the best for Christmas. Perhaps you can enjoy your holidays watching some of my 007 Special Agent James Gout movies:-

• Gnarledfinger Mixing business and gout! Mixing thrills and gout! Mixing danger and gout! Investigating a gout cure magnate's allopurinol smuggling, 007 uncovers a plot to contaminate the little-known Fort Knox anti-gout vaccine reserve.
• Purines Are For Never...for never...for never...for never. Agent 007 goes to Las Vegas to investigate the disappearance of purines in seafood and discovers the involvement of his archenemy, Blofeld.
• Goutodrossy James Gout's all time inflammation low. A purine-enriched egg found with a murdered British agent puts 007 on the trail that leads to a plot to give gout to thousands to weaken NATO defences in Europe.
• For Uric Acid Only Gout Hurts Everything - Agent 007 Gets His Back. Agent 007 is assigned to hunt for a lost British uric acid lowering device and prevent it from falling into enemy hands.

Special Agent (2)007

James Gout

P.S. If you're a Wal-Mart shopper, see if you can find my movies amongst .97 Cent Shipping on over 15,000 Movies at Walmart.com
There are thousands of other savings on toys, books and electronic gifts during December.

Gout Treatment Research

The meetings cover all aspects of arthritis. I've summarized those relating to gout treatment here.

The first 3 studies relate to different aspects of trials of a new drug, febuxostat. The fourth looks at that most important aspect of gout - diagnosis. Other studies investigate wider aspects of gout, including it's incidence and measuring it's effects.

Effect of Febuxostat or Allopurinol on the Clinical Manifestations of Gout:

Reduction in Gout Flares and Tophus Size Over Time in the EXCEL Trial

Robert L. Wortmann and others presented an interim analysis of a long-term open-label study to determine if subjects treated with febuxostat or allopurinol, and maintaining serum urate levels (sUA) <6.0 mg/dL, experienced reduction in gout flare frequency and tophus resolution.

Febuxostat has been developed by TAP Pharmaceuticals as an alternative to allopurinol. It is undergoing trials prior to public release, expected in 2007.

As with allopurinol, febuxostat can trigger gout flares in it's early stages, as existing uric acid crystals start to dissolve and expose themselves to the immune system. In these cases, subjects were prescribed naproxen or colchicine to help relieve pain.

The most common side effects for febuxostat are abnormal Liver Function Tests, headache, hypertension, diarrhea, and arthralgia/stiffness. The most common side effects noted for allopurinol are abnormal Liver Function Tests and rash.
I've shown the reduction in gout flares in the chart above. The chart data is taken from the abstract of this study which you can read by clicking on the chart.

The FOCUS Trial 48-Month Interim Analysis:

Long-term Clinical Outcomes Of Treatment with Febuxostat in Subjects with Gout in an Ongoing Phase 2, Open-Label Extension Study

H. Ralph Schumacher Jr, and others, presented an interim analysis at 48 Months, which evaluated clinical outcomes of long-term daily treatment with febuxostat aimed at maintaining serum uric acid (sUA) levels <6.0 mg/dL (357 µmol/L) in subjects with gout. Subjects completing a 4-wk study of the safety and efficacy of febuxostat were eligible to enroll in the Febuxostat Open-label Clinical trial of Urate-lowering efficacy and Safety (FOCUS).
Overall incidence of gout flares requiring treatment declined markedly by 2 years and continued over 4 years of febuxostat treatment (see chart). After the first year of stable dose, subjects, on average, had less than 1 gout flare per year.

Of the 26 subjects who entered the study with one or more tophus, over 75% had no discernable tophi after one year.
Conclusion: This is longest clinical study to date of febuxostat therapy. Febuxostat successfully reduced uric acid levels below 6 mg/dl and maintained that level over 4 years. Gout flares and tophi were both reduced.

Allopurinol Intolerant Patients Treated with Febuxostat for 4 Years

Michael A. Becker and others followed up a 6-month report on allopurinol intolerant subjects who have received febuxostat treatment for at least 4 years.

They report that 2% of people can have severe reactions to allopurinol (full details in the online abstract). 3-10% have reactions that, whilst not life threatening, are sufficiently unpleasant to render them unable to take allopurinol.
Allopurinol side effects in the subjects included:

• GI intolerance/ Nausea
• Severe diarrhea
• Drowsiness
• Hives
• Rash

Conclusions: Treatment with febuxostat for 4 years was safe, effective, and well tolerated in a small group of 6 subjects with a history of allopurinol intolerance.

Fine-Needle Aspiration (29G) of First Metatarsophalangeal Joint is Effective and Well Tolerated

Francisca Sivera and others designed this study in order to show the effectiveness and tolerability of fine needle aspiration of the 1^st metatarsophalangeal joint.

First of all, a confession - the picture on the right is an injection rather than an aspiration, but you get the point. If you have this procedure, why not take a camera and send me a better picture.

The study concludes that the procedure is well tolerated by patients, even when it is carried out by trainees. My experience confirms this - my own gout diagnosis was confirmed by this procedure in my ankle. I recall asking the doctor when he was going to do it, about a minute after he had finished!

In my opinion, this study is as important as the febuxostat trials. Each year thousands of patients fail to get gout treatment, because their symptoms do not follow the classic pattern. Similarly, patients suffering pseudo-gout, and possibly other forms of arthritis or even infection, are wrongly diagnosed with gout.

Aspiration (also known as arthocentesis ) has been underutilised for fear of inflicting pain. This study (abstract online) shows these fears are groundless.

Statistical Gout Studies

The remaining four studies are all based on statistics. Two look at measuring the effects of gout. The other two are general statistical analyses.The two general statistical analyses are:

• Characteristics of Patients Who are Frequent Users of the Emergency Department for Acute Gout
  Charles E. Griffith, III and others, report that over one third of patients visiting ED during 2002-2005 had 3 or more visits for acute gout. Only half were receiving treatment to lower uric acid. Less than 10% were referred to a rheumatologist. The writers conlude that Emergency Departments would be a good place to start care plans aimed at improving gout patients recovery.
• Retrospective Claims Analysis of Gout Drug Utilization, Compliance and Associated Serum Urate Levels
  Rachel Halpern and others, presented a study of over 25,000 gout patients extracted from the database of a major health care plan. Key points from this data-rich report include:
  • High blood pressure and cholesterol levels are common in gout patients (both over 40%)
  • Allopurinol was the most prescribed medication, but less than half continued to take it. Of those that did, only 35% achieved suitable reductions in uric acid levels.

Dare I suggest that the "take these pills and go away" culture remains strong when the medical profession is presented with what is commonly perceived as a lifestyle disease?

The 2 studies about measuring the effects of gout are:

• Evaluation of the Psychometric Properties of a Gout-Specific Patient Reported Outcomes (PRO) Instrument
  J. D. Hirsch and others note that there is no currently acceptable method to measure the effects of gout. They conclude that it is possible to develop a reliable measure through a standard questionnaire. However, further research is necessary to refine structure, detect change over time, and tie in with minimum clinical measurements.
• Patients' Perspective on Status of Gout Control: Impact on Health Related Quality of Life (HRQoL)
  S. J. Lee and others note that little has been done to measure the impact of gout on quality of life. Their study of 151 gout patients reports that, despite medical care, pain was common and quality of life low. They conclude that physicians may underestimate the severity of gout and that understanding the effects on quality of life will help to find the best treatment.

Now that it has been confirmed that medical care for gout is often less than satisfactory, perhaps we should do something about it. If you have had good experience of gout care, please share your experience. If we can establish good standards for best practice, it gives all of us a chance to constructively campaign for better advice and treatment.

Competition

The winner is freedom for the message about acidic medication. I'll be contacting freedom soon.

I've now dropped the idea of a competition. Perhaps something simpler would be better? If you've any ideas, please let me know.

Recent GoutPal Changes

The main change is my introduction of an entertainment section. This is a look at the lighter side of gout. I've moved my first ever gout page (yes, that song!) and it's been joined by a poem from JIM from London.

I'm adding famous gout victims to this section. As well as being interesting in their own right, I'm using these people to develop an online calendar. I had hoped that this would be ready for this issue, but I will announce it properly next month.

Coming Soon on GoutPal

There'll be some more pages on remedies and treatments thanks to messages I've received from all over the world.

I've got plenty of ideas for 2007 from these messages. Please keep your questions and comments flowing.

A final note of thanks from the editor

Thank you for reading this issue of GoutCaster. If you've any ideas for improving it, please write to me.

If you know anyone else who might be interested, please forward this to them. I'm particularly keen to get views from the medical profession (if I can understand them), so why not send it to your doctor?. If you do forward it to someone it is a good idea to remove the final two paragraphs, which are automatically added so you can manage your subscription.

If you've been sent this by a subscriber, why not sign up for your own copy? Just fill in this simple form

Thanks again for reading GoutCaster.

James Gout

Special Note:
Please accept my apologies for the delay in sending this newsletter. It has been held in a queue at my webhosting company.
Please note that there may be a small amount of disruption to GoutPal.com during December as I move to a new hosting service.