Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. Joining me today is Dr. Angelo Gaffo. He's a rheumatologist and a professor of medicine in the division of rheumatology at UAB Medicine, and he's here to give us a better understanding of gout flare. Dr. Gaffo, it's a pleasure to have you join us today. So I'd like you to start by telling us the scope of the issue we're talking about here today. What is gout? And tell us a little bit about the prevalence of it.

Dr Angelo Gaffo: Oh, thank you very much for the invitation, Melanie, I am very happy to be here. Gout the most common inflammatory arthritis, this is not very well known sometimes, most people think about rheumatoid arthritis as the most common arthritis, with inflammation that patients struggle with. And rheumatoid arthritis is very important, of course, but gout is probably at least three or four times more common than rheumatoid arthritis disease. The issue is with gout, For the longest time, has been poorly understood or minimized or seen as a nuance, more than a real problem that patients struggle with.

So, again, very common, inflammatory arthritis becoming more common. epidemiological studies have confirmed that a number of factors are making the frequency of gout increase and factors associated with metabolic syndrome, obesity, increasing diabetes, for example, frequencies. Also share common pathways with how elevations in uric acid or serum urate, and ultimately gout because both of them are so intimately related. Go up, so very well documented in all kind of civilizations around the world that the frequency of gout is going up very rapidly.

Melanie Cole (Host): Well, thank you for that. So, Dr. Gaffo, speak a little bit about the clinical presenmtation, as you're speaking to other providers about what they're going to see if someone goes first to their primary care provider before they see a rheumatologist, tell us a little bit about how it manifests.

Dr Angelo Gaffo: Gout has been very well described in the medical literature for probably centuries. it commonly presents as an acute and intensely painful attack of joint pain and swelling, usually located in the lower extremities. Most commonly in the first MTP of one of the feet, the classical episode is known as [inaudible] and so the patient has typically excruciating pain in the base of one of the toes. Great toes. However, it can involve the ankles, it can involve the knees. sometimes we see it in other joints, in the upper extremities. Although the most common location for the first attacks are usually in the lower extremities.

These attacks, if left untreated they usually last for a period of, three to seven days during these attacks that commonly come not only with pain, but with swelling in the joint, redness in the joint, the joint is quite warm. and they're quite disabling patients usually cannot do too much during the episode of attack. They cannot walk, for example, if it's in one of the feet. And typically, the degree of disability is such tha t patients need to go to an emergency room, emergency care, Or sometimes know they cannot enjoy the daily activities.

Another important aspect of gout that is less common but also happens is some patients that have a persistently high levels of uric acid can sometimes develop. These masses of urate under the skin, which are called tophi. And they can be, very, aesthetically, disabling the form and also they can damage the joints. They can lead to join the form, joint destruction and a lot of disability chronically in the chronic phase of gout. In between the flares, the patients are usually largely asymptomatic, and that's why usually gout, sometimes is so poorly understood and treated.

It's seen as a self-limiting problem. But these attacks, if a patient is not taken care of well, these attacks, usually become more and more frequent. And at some point gout becomes a chronic arthritis, pretty much like rheumatoid arthritis, or psoriatic arthritis, for example, that have constant pain and swelling. Gout transforms into that, and at that stage is much harder to treat.

Melanie Cole (Host): So interesting and it's definitely something that I think that not every provider is aware of. These clinical implications that you're discussing here today, tell us about the work, Dr. Gaffa, that you've done in the past year that's led to a better understanding of the manifest. Stations, and also you've worked with an international group to create a validated definition of flares for research, which is a great improvement for future clinical studies. Speak a little bit about the work that you've been doing and how you envision this research translating to better patient care.

Dr Angelo Gaffo: Yes, certainly. Problems that we have with gout is that, There was not a standardized way, to measure improvement or outcomes in gout. So we understand from, clinical experience and what patients told us that patients care a lot about flares. Patients care a lot about the tophi. Patients care a lot about the disability, the quality of life part of it, and from the point of flares is a very fundamental characteristic of the gout experience. This is what patients probably care most about. And we did not have a standardized way to define or measure flares.

So if you wanna know, for example, you create a clinical trial. Everybody was measuring or defining flares in their own way. So we need to have a unified way of defining what a flare is and also how to measure them. Back a number of years ago, we came together, in an international group of investigators that care a lot about, gout and we enrolled, about 200 patients, with. that gave us data and told us. I think I'm having a flare, or I don't think I'm having a flare on this visit. And we collected, which symptoms did they have? And we also had a experienced rheumatologist on these different sites around the world that saw the patient without knowing what the answers to those questions were.

And that they examined the patient, talked to them, and they gave us their opinion. Is this patient having a flare or not? So we, basically, did a logistic regression analysis, to define which. Defined according to the expert rheumatologist that was on site, the presence or no presence of a flare And we came with a number of, defining features of what the flare definition was. One was, that the pain level that the patient reported needed to be at a level of three or more in a zero to 10 numeral rating scale. That scale that you get, of course everywhere, you know, was your pain level. From zero to 10.

 A patient needed to have at least one joint, which was swelling and at least one joint, which was warn. And surprisingly also another feature was when the patient actually thought, yes, doctor, I'm having a flare. I know my body, my experience with gall in the past, and this feels like a flare, that also, So of all these four factors that I mentioned to you, the pain score, the patient, the fine out flare counted. One of the joints being swollen and one of the joints being warm. If the patient had three, out of four that was highly sensitive and specific our sensitivity was 91% and specificity was 82%.

For defining an independent way, the expert rheumatologist confirmed that this patient had a flare. we also did a validation exercise of this definition in another independent, group of even higher of 500 patients from now, from 17, other international sites, and we confirm this very high sensitivity and specificity values. So, we have a definition now, which has been very well validated, and we expect that all future clinical trials in gout, are now incorporated this definition and that now we can compare different studies.

Because this is the problem that a company that study in their, gout flare treatment and a different company that's in another flare treatment, how do you compare that the patients were enrolled in the same way that the patients kind of followed a pattern to be enrolled. And now we have that. So hopefully it's gonna advance the science of improving a care for gout flares in the future. A word of caution, though, the way we created this definition, at this moment only validated clinical research, so I cannot tell a colleague this is the way to measure flares in your practice.

So this has not been conceptualized, created, or validated for a clinical practice. This so clinical practice, you still need to go with your experience and knowing how gout present. You can probably imagine that these elements are, the way patients present in practice, but it was not the way it was conceptualize.

Melanie Cole (Host): So even though it's not standardized, still very well done and such excellent points that you've made. Dr. Gaffo, tell us about your work with collaborators to understand the patient's perception of the burden that flares impose. This is such an interesting aspect of this condition because we know that that kind of a burden is really subjective and not objective. Tell us about this.

Dr Angelo Gaffo: We have worked with a very close collaborator group in New Zealand and also with other groups to understan d in general the, burden that flares imposed in patients with gout. And is it very interesting because different patients have different perceptions of what's important for them and what they value most. And in many cases, the pain in itself that gout flares they bring up, are one of the main components of the burden of the flare. But there are other elements to, the number of de duration of the flare, of course, is something that patients also impose a heavy burden on them.

The number of days that you cannot do things, the number of days that you, for example, you are out of work, as somebody that has a physical work that needs to go to, do something physical and they are missing, work days. If you have to go to an urgent care or a hospital, the economical cost, the time, the anxiety of being admitted, for your flares, of course is important. Quality of life issues. The anxiety about, when is the next flare going to come. Or I'm missing my daughter's wedding, or just the perception that you have to kind of always be, aware that this may come to me at any moment and it's gonna sideline me.

all of these were very important aspects that, some multidimensional impact of gout flares. Not only the pain at that moment, but also, a lot of other aspects. We did, quite a bit of qualitative studies with patients too, in which they gave us testimonials about the psychological impact, impact on family and social life in all the aspects that I just mentioned.

Melanie Cole (Host): So comprehensive and I'm sure that not many people always think about. Those comorbid situations that go on with these patients and the effect on the quality of life, which is just so important. I'd like you to wrap up Dr. Gaffa with your best advice and key messages that you would like other providers to take away from this podcast so that they can better serve their gout patients.

Dr Angelo Gaffo: Yes, certainly. when a patient comes to a colleague's practice, for example, in an urgent care or an emergency room, with a clinical presentation consistent with a gout flare. Podagra or a very, hot and swollen joint and, there are many ways to treat them. There is the drug called Colchicine. There are steroids, there are anti-inflammatory drugs such as ibuprofen or naproxen. All of these are, very Effective and standardized for treatment of gout, but try not to just leave the care at that aspect.

If the patient, doesn't have established primary care, or, has not been referred to a rheumatologist, probably taking the extra step of trying to coordinate that will be quite helpful because at the end, what is gonna prevent the recurrence of flares is, the treatment of gout as a chronic disease. We rheumatologists know that we need to lower the serum, urate or uric acid values in order to prevent flares from coming back in the future. so once gout is well-treated, flares stop.

And probably the main message that I give to anyone that sees a flare of gout in their practice is take five, 10 minutes to explore if the patient is under the care of a rheumatologist or if the primary care doctor is already trying to manage it. And if that is not happening, if you can arrange for follow up in the rheumatology clinic, That will be the way for That patient hopefully not coming back with another gall flare in the future.

Melanie Cole (Host): Thank you so much Dr. Gaffo for joining us today and sharing your incredible expertise in this area. I hope you'll join us again and update us as you learn more. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.