How much uric acid can be controlled to reduce gout attacks?

*For medical professionals to read and reference Many people with gout think that as long as they don’t have symptoms, their gout is well controlled.
Is this true? Pharaoh next door has been suffering from gout for decades.
Last year, he took medicine regularly under the guidance of the doctor, and finally managed to control the symptoms.
However, every time he went to the hospital for re-examination, the uric acid level was still five or six hundred
.

The doctor suggested to further adjust the drug to control the uric acid level, but Lao Wang disagreed: "No, no, I haven't had pain a few times this year!" The source of gout is uric acid.
In fact, not only is the patient uncertain about the goal of gout management, Doctors also hesitated on the issue
.

The American College of Physicians Clinical Practice Guidelines: Management of Acute and Recurrent Gout [1] published in 2017 believe that most patients with gout for the first time, or patients with infrequent gout attacks, do not recommend long-term uric acid-lowering therapy
.

However, previous studies have clarified the close relationship between hyperuricemia and gout [2]
.

Is it necessary to control uric acid within the target range based on the control of gout symptoms? Let's start with the pathogenesis of gout
.

Gout is a chronic disease caused by the disorder of purine metabolism, increased synthesis and/or decreased excretion of uric acid, and caused by the combined effects of genetic factors and environmental factors [3]
.

Disorders of purine metabolism are the main cause of increased uric acid production, and decreased uric acid excretion is also a common pathogenesis of gout
.

Therefore, from the definition, we can see that the key to gout is the increase of uric acid in the blood
.

Therefore, in order to control the attack of gout, the treatment of lowering uric acid is essential
.

But how much uric acid in the blood is controlled to meet the standard? A recent study published in The Lancet Rheumatology (The Lancet Rheumatology) gave the answer [4]
.

Figure 1: Paper title Uric acid achievement is a goal of gout management Physician-Led Usual Care Group) to analyze data on urate-lowering therapy for gout patients in both studies
.

Among them, the study defined the individuals whose serum mean uric acid concentration was lower than 6 mg/dl (0.
36 mmol/L) at 6, 9 and 12 months after baseline as serum uric acid responders, that is, the uric acid standard group
.

Patients with substandard mean serum uric acid concentrations were defined as non-responders to compare the primary and secondary outcomes of serum uric acid responders and non-responders
.

The primary outcome of the study was at least one gout attack, and the secondary outcome was the average number of attacks per participant per month from 12 to 24 months after baseline
.

From combined individual data from two trials, the study identified 343 serum uric acid responders and 245 serum uric acid non-responders
.

The results of the study were as follows: Primary outcome: Serum uric acid responders had significantly fewer gout attacks than serum uric acid non-responders between 12 and 24 months [91 of 343 (27%) vs 156 of 245 (64%) ); p<0.
0001]
.

Secondary outcomes: The mean number of episodes per month in serum uric acid responders was significantly lower than in serum uric acid non-responders between 12 and 24 months (p<0.
0001)
.

This association was independent of the initial randomized treatment assignment
.

Therefore, the study concluded that achieving a mean serum uric acid concentration of less than 6 mg/dl (<360 μmol/L) was associated with the absence of gout flares in gout patients and a reduction in the number of gout flares over the subsequent 12 months
.

That is, in gout management, targeting serum uric acid levels below 360 μmol/L can significantly reduce the number of gout attacks
.

This treatment target is also the same as the uric acid control target for gout patients in the "China Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" [5] published in China in 2019
.

The correct management process of gout patients The Chinese Medical Association Endocrinology Branch follows the international GRADE classification method, adopts the clinical evidence-based guideline formulation process, and multidisciplinary experts including methodologists participate in the formulation of the 2019 version of Chinese hyperuricemia and hyperuricemia.
Guidelines for the diagnosis and treatment of gout" [5]
.

The guideline contains 3 general recommendations and recommendations for 10 clinical problems, covering the diagnosis, treatment and management of hyperuricemia and gout; the concept and diagnosis and treatment of subclinical gout and refractory gout are proposed for the first time; Recommendations for problems related to alkalized urine were made for the first time; drug selection for common comorbidities of gout was recommended for the first time
.

It aims to provide the best basis for clinicians and related practitioners to make diagnosis and treatment decisions on hyperuricemia and gout
.

Among them, the editor extracted the flowchart of the diagnosis and treatment of hyperuricemia and gout summarized in the guideline for readers to learn and reference
.

Figure 2: Flow chart of the diagnosis and treatment of hyperuricemia and gout [5] At the end of the article, the editor would like to say a few words to the gout patients and their families: gout is a chronic disease.
Regularly review the blood uric acid level, adjust the drugs in time, and strive for standard treatment! References: [1] QASEEM A, HARRIS RP, FORCIEA M A.
Management of acute and recurrent gout: a clinical practice guideline from the American College of Physicians [J].
Ann Intern Med, 2017, 166(1):58- 68.
DOI: 10.
7326/M16-0570.
[2] Guidelines for the diagnosis and treatment of hyperuricemia and gout in China (2019) [J].
Chinese Journal of Endocrinology and Metabolism, 2020 (01): 1-2-3-4-5-6 -7-8-9-10-11-12-13.
[3]Shi Bai,Yin Haibo,Zhang Jinhua.
Research progress in modern epidemiology and pathogenesis of gout[J].
Rheumatology and Arthritis,2012,1 ( 06):51-55.
[4] Lisa K Stamp, Christopher Frampton, Jasvinder A Singh, et al.
, (2021).
Association between serum urate and flares in people with gout and evidence for surrogate status: a secondary analysis of two randomised controlled trials.
The Lancet Rheumatology.
DOI: https://doi.
org/10.
1016/S2665-9913(21) 00319-2[5] Chinese Guidelines for Diagnosis and Treatment of Hyperuricemia and Gout (2019)[J].
Chinese Endocrinology Journal of Metabolism, 2020(01): 1-2-3-4-5-6-7-8-9-10-11-12-13.