Beyond Medical Treatment: Surgical Treatment of Gout
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CRYSTAL ARTHRITIS (M PILLINGER & M TOPROVER, SECTION EDITORS)
Beyond Medical Treatment: Surgical Treatment of Gout Jonathan Carcione 1
&
Shari Bodofsky 1 & Brian LaMoreaux 2 & Naomi Schlesinger 3
Accepted: 15 November 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review Medical treatment with urate-lowering therapy (ULT) is efficacious. A recent publication suggested that surgery in gout is more prevalent than previously reported. This revelation led us to review what is known about surgical treatment of gout. Recent Findings The Google Scholar database (January 1, 2014–January 1, 2020) found 104 publications with a total of 169 gout patients, with an average disease duration of 6.7 years. Most (68%) were not on ULT. The mean pre-operative serum urate levels were 9.19 mg/dL. One hundred thirteen patients underwent tophi excision, while in 33 patients, tophi were found during surgery. The majority of the surgeries were performed in Asia and Europe. Summary Most patients were not taking ULT at the time of surgery, leading to hyperuricemia. This can result in tophi reformation post-surgery. The role of surgery should be a last-line treatment and until recently has only been demonstrated through case reports. Keywords Gout . Tophaceous gout . Surgery . Surgical treatment
Introduction Gout is the most common inflammatory arthritis worldwide. Hyperuricemia is defined as a serum urate (SU) level ≥ 6.8 mg/dL, the physiologic saturation threshold for uric acid. Persistent SU levels above 6.8 mg/dL can lead to monosodium urate (MSU) crystals deposition in and around joints and soft tissue. Lowering SU to a target of ≤ 6 mg/dL in combination with acute and chronic anti-inflammatory drugs can lead to gout being under control. Since its Food and Drug Administration (FDA) approval in 1966, allopurinol has been the drug of choice for treating hyperuricemia in gout patients. Febuxostat, another xanthine oxidase inhibitor, was FDA approved in 2009 [1], This article is part of the Topical Collection on Crystal Arthritis * Jonathan Carcione [email protected] 1
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
2
Horizon Therapeutics, Lake Forest, USA
3
Division of Rheumatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School Gout Center, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
becoming a mainstay ULT alongside allopurinol [2]. However, in 2019, the FDA issued a public safety alert due to a reported increased risk of death in febuxostattreated patients than allopurinol-treated patients, leading to a boxed warning for febuxostat [3]. In addition, lesinurad, a uricosuric drug, was taken off the US market in February 2019. With febuxostat being a limited option for many gout patients who have a risk of cardiovascular disease, lesinurad off the market, probenecid contraindicated or not recommended in many patients due to renal considerations or drug interactions, the options for urate-lowering in gout are limite
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