Conflict on ACR and ACP Guidelines for Gout Management [Interview][Transcript]

Dr_N_Lawrence_Edwards_gout_researchGuest: Dr. N. Lawrence Edwards
Presenter: Neal Howard
Guest Bio: Dr. N. Lawrence Edwards is a specialist in internal medicine and rheumatology, and serves as professor of medicine in the Division of Clinical Immunology at the University of Florida in Gainesville, Florida. He is also program director of the Medicine Residency Training Program and vice chairman for the Department of Medicine at the University. In addition, he is the chairman and chief executive officer for the Gout & Uric Acid Education Society.

Segment overview: In this segment, Dr. N. Lawrence Edwards, MD, rheumatologist, discusses new gout research and why medical professionals should adhere to the American College of Rheumatology (ACR) guidelines vs the American College of Physicians (ACP) new guidelines which conflict with the ACR.

Transcription
Health Professional Radio – Gout Management

Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard. Glad that you could join us. Our guest is returning to speak with us Dr. N. Lawrence Edwards. He is Rheumatologist. He’s here to discuss with some new gout research. Also to talk about why medical professionals suited here to the American College of Rheumatology or ACR guidelines as opposed to the American College of Physicians or ACP guidelines. This guidelines are apparently conflict in. Dr. Edwards is here to clear the air force. Welcome back to Health Professional Radio Dr. Edwards.

Dr. Lawrence Edwards: Thank you Neal. It’s a pleasure being with you.

N: When you were here before we talked a little bit about gout. For our listeners who maybe unfamiliar, talk about exactly what gout is? What are some of the symptoms to look for?

E: Sure Neal. Gout is the most common inflammatory arthritis that there is. So you hear a lot on TV about rheumatoid arthritis and psoriatic arthritis but gout is at least 4 or maybe 5x more common than either one of those forms of arthritis. None of the flicks about 9 million people in this country, it can be devastating and destructive form of arthritis. Over the years not only do people have the types of symptoms that everybody thinks about with gout which is extremely painful, abruptly swollen joints, like their great toe or their ankle or their knee that leads a person immobilized for three or four days. It really can progress on to where they have destruction of the joints and pain everyday. It can lead to difficulty, just carrying out activities of daily living.

N: You talk about how widespread gout is. A survey last year suggested that most of us don’t even understand gout. You explained the basics to us just a minute ago. But patients who are diagnosed with gout remain less than vigilant in taking the right steps to manage their gout. Why do you think that is?

E: I think most of these comes down to education, Neal. I think that our physicians are very busy in their office. I don’t think patients are told the simple basics of the disease process that they have. Gout is a chronic disease caused by elevated uric acids in the blood. Most people with gout and viewed the disease as being something that they’ve brought on themselves. They’ve heard this for a long time maybe even in their family. People that have gout that the myth is that they have the disease because they over indulged too much of one type of food or the other, too much strength. Because of that they’re somewhat embarrassed to have the disease, but the truth is that it’s a metabolic condition and most of the predisposition to having gout is inherited. The higher uric acid level is something that they have throughout their adult life, it simply needs treatments like any other chronic disease like diabetes, or hypertension or high cholesterol. The gout is the clinical manifestation and people focus on that but it’s a disease that’s always there not just between those flares or occurring.

N: If we going to shed some light on gout. How can we be as effective as possible when you have differing opinions as to its treatment and its management? Talk about some of this conflicting guidelines between the ACR and the ACP when it comes to gout uric acid.

E: Sure Neal. You should say right of that I’m a member both of those organizations. I’m a master of the American College of Physicians. I’m a master of the American College of Rheumatology and considered an International Gout expert. The gout guidelines that were offered by the American College of Rheumatology are very similar to the guidelines that came out from the similar group in Europe, as well as the British Rheumatology Society. In that there was a recommendation that all people with gout after they’ve had their first, their second flare should have their uric acid lowered by medication until the serum uric acid level is less than 5 or 6 mg per deciliter, which we put it on a normal range. That’s essentially, internationally accepted as a treatment standard and we’ve now called that a treat to target sort of mode and we picked that number because we know with uric acid is lowered to this level that overtime the accumulation of uric acid around the body will dissolve and the number of flares that a person has or gradually dissipate and until they no longer have any gout flares. Now, remember that they still have a metabolic disease that’s going to cause uric acid to go up if they’re not taking medication to drop down. The recommendation is to get on the uric acid lowering therapy and they can continue to take it life long. The American College of Physicians recently came out and said that, “Today let us support this approach that’s accepted again internationally was circumstantial, that it didn’t have a high level of research integrity.”, but I think that they missed the boat there. It would be very difficult to do long terms with this drugs just because the drugs is supportly taken. There’s a plenty of data to under pin the recommendations from the American College of Rheumatology and I believe that the treat to target approach that those guidelines endorsed are the correct ones, the alternative approach which is what the American College of Physicians discuss is that treat to avoid symptoms which is just looking at a very superficial the near of gout, are not recognizing the consequences of not lowering the uric acid, will ultimately result at irreversibly destructive form of arthritis and disability.

N: In your opinion do you think that some of this conflict between the guidelines of ACP and the ACR being a member of both of those organizations, do you see a resolution prior to the launched of the gout specialist network? Or is this anticipated launch of this network going to facilitate a better dialogue between professionals in both of these organization to kind of get everybody on the same page?

E: I think that there’s ample evidence and since the American College of Physicians guidelines will come out. There’s been a number of editorials and discussion groups about just where that society guidelines went wrong. There are excellent on going studies to answer all the questions about uric acid lowering. Our whole populations studies is going on currently in New Zealand. Also in Japan not only do all patients with gout could put on uric acid lowering therapy. We can observe those people over the year to see how much better they do than in a prior process where that wasn’t happening but even if you have an elevated uric acid and no gout symptoms, it becomes the established approach in Japan to go ahead and treat with uric acid lowering therapy. We’re going to get a whole lot of data over the next several years from those large populations studies to, well any rebuttal to the ACR guidelines.

N: Would you like to see an adherence to the one policy and in abandoning of the other? Or Would you rather see emerging of the two streamlining the two
into one policy that works well across the board?

E: The ACP guidelines do have some good parts to it. I should say that they endorse the ACR guidelines to important recommendations about educating the patients so that they understand the disease, understand the medications that they’re being placed on and what they do. I think that that’s the answer to most all the problems in treating gout is understanding by the patients on what’s going on. To that end we at the gout uric acid education society set out to establish the gout specialist network, you mentioned that before Neal, and it’s our new bringing file this year, where we’ll really identify both generalist as well as specialist around the country who have an interest in gout, like to treat people with gout, take the time to explain to their patients about the disease process is and how to monitor to it. Then will make that data available at our website at the gout society, at gouteducation.org. Reason we’re doing this is so we get called many, many times a week on our website asking for help that they have physicians that seems to be ignoring their gout and not doing anything about it and yet they’re hearing that more should be done. So, we are trying to help them by identifying people maybe in their environmental, would have some special expertise for this disease.

N: I’m certainly appreciative that you could come in again and speak with us doctor.

E: It’s always fine Neal. Glad to be here.

N: You’ve been listening to Health Professional Radio, this health supplier segment with Dr. N. Lawrence Edwards, Rheumatologist, discussing some new gout research. Transcript and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm. You can subscribe to this podcast on iTunes, listen in and download on SoundCLoud.