At the 2022 American College of Rheumatology, ACR Convergence meeting, Dr. Sarah Black, a rheumatology trainee at Musgrave Park Hospital, Belfast, Northern Ireland, reported results from the TICOG (Tight Control of Gout) trial.1 The main findings from this a randomized, controlled trial showed that patients with gout who had monthly up-titration of urate-lowering therapy visits for intensive treat-to-target were more likely to achieve their goals at 1 year when compared with patients who received conventional gout management.

Urate-lowering treatment among patients with gout is often challenging in that patients frequently suffer insufficient effectiveness or adverse events due to comorbidities, concurrent medications, and altered pharmacokinetics.2 According to Dr. Black, investigators of the TICOG study asked whether some of those challenges could be met with an altered management strategy. To that end, TICOG compared conventional management of gout with monthly urate-lowering up-titration in order to achieve and maintain serum urate levels at a target of 0.30 mmol/L (5 mg/dL), which is in line with  European Alliance of Associations for Rheumatology (EULAR) recommendations.

Participants aged 18-85 (N=110) were prospectively enrolled in the study and randomly assigned to a“tight control” or conventional treatment group. Control conventional treatment arm participants received ongoing care from their general practitioner and were assessed at the study site at months 0, 6, and 12 months, whereas those in the intervention arm were assessed at the study site every month for 12 months. At baseline, all participants received the same gout education, including advice on lifestyle changes. All patients received colchicine or NSAID prophylaxis for gout flares for the first 6 months, depending on their comorbidities.

The primary outcome of reaching the target serum urate level of less than 5 mg/dL (<0.30 mmol/L) was met in the  “tight control” arm (89.4% vs39.6%; P<0.001). In addition, there was a reduction in ultrasound features of gout at the knee, with improvements in 63.0% of the “tight control” group, compared with 14.0% of the conventional group (CI, 0.01%-0.97% ; P<0.043). Likewise, tophus size at the first metatarsophalangeal joint was significantly reduced between the tight control and conventional treatment groups (median reduction decreased the size by -4.65 mm and -0.30 mm, respectively; P=0.003). Scoring the presence/absence of a double contour sign at the first metatarsophalangeal joint at the final site visit also revealed a difference; a double contour was present more frequently in the “tight control” (62.5%) group compared with the conventional treatment group (40.0%).

The authors concluded that a “tight control” strategy featuring monthly visits and up-titration lowered urate to a greater extent than conventional management, reduced tophus size in the first metatarsophalangeal joint, and improved grayscale synovitis on ultrasound significantly more than with conventional management

Physician’s Weekly was able to speak with Dr. Black briefly about her presentation.

PW: Is gout managed best in primary or secondary care?

Dr. Black: This study demonstrated that tight control of gout leads to highly statistically significant improvements in serum urate levels and resolution or at least improvement of ultrasound features of gout. Based on these outcomes, we question whether gout is best managed in primary or secondary care. We think there is an argument for establishing specialist gout clinics with more time to focus on patient education to help improve outcomes. These clinics could be led by allied healthcare professionals, such as specialist nurses and pharmacists, so their structure can best meet the individual clinic’s needs. In this study, secondary care seemed to be better, but there is no reason why primary care cannot be equally effective.

Are current guidelines adequately stringent with regard to serum urate levels?

Perhaps not. The gout management guidelines issued by the British Society for Rheumatology in 2017 call for a target serum urate level of less than 5 mg/dL, whereas the ACR’s 2020 guideline for the management of gout endorses a treat-to-target management strategy that aims for a serum urate level of less than 6 mg/dL. There is still a need for additional data and consensus on our goals. Harmonization of our approaches will help manage our patients better. We learned here that monthly monitoring may be key to staying on top of this disease and helping patients reduce the burden of this disease.