Majority of Hyperuricaemic patients have Co-existing conditions like CVD, Diabetes and Chronic Kidney Disease- Austin Stacks

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 Lower uric acid will protect the kidney 

Majority of Hyperuricaemic patients have Co-existing
conditions like CVD, Diabetes and Chronic
Kidney Disease- Austin Stacks

Treatment with Febuxostat lowers uric acid 
and alleviates systemic hypertension

Physicians should   regularly screen for uric acid levels in
patients with co-morbidities - Prof. Waris Qidwai

KARACHI: Majority of the asymptomatic Hyperuricaemia patients have co-existing conditions like cardiovascular diseases, hypertension, diabetes mellitus and chronic kidney disease. Treatment slows down the kidney failure. Hence this word should be removed from the medical literature.  This was stated by Dr. Austin Stacks a noted research scientist, consultant Nephrologist from University Hospital Limerick, Ireland. He was speaking at the First Hyperuricaemia Summit organized by Hyperuricaemia Advisory Council at College of Physicians & Surgeons of Pakistan on March 21, 2017.  Five regional centers of CPSP at Hyderabad, Multan, Faisalabad, Larkana and Peshawar were also linked through the video conferencing facility available at the CPSP. Hence the meeting was very well attended not only at Karachi but at other centers as well where the participants also actively participated in the discussion.


Prof. Austin Stacks

In the beginning of his presentation Prof.Austin Stack commended PharmEvo for its efforts to create awareness about Hyperuricaemia and Gout among the healthcare professionals. He was delighted to see that quite a number of young medical students and nurses apart from senior healthcare professionals had participated in the poster competition on Hyperuricaemia.  Uric Acid, Prof.Austin said is a significant risk factor for Gout. If untreated, it leads to deformity, deformed joint of hands. He further pointed out that in case of asymptomatic Hyperuricaemia with no clinical gout but raised uric acid, most of these patients have high risk of many co-morbid conditions like myocardial infarction, stroke, metabolic syndrome, hypertension and diabetes. The question arises should these patients be treated or not? He then explained that Hyperuricaemia is just like hypercholesterolemia. Cholesterol does not cause symptoms but it is a risk factor for cardiovascular diseases. Hence, it can be compared with hypercholesteraemia. Elevated uric acid could be present in the absence of gout. Asymptomatic Hyperuricaemia can be with elevated uric acid in the absence of gout, elevated uric acid in the absence of chronic conditions and most patients with Hyperuricaemia have chronic conditions. Hence Hyperuricaemia is associated with gout, it is linked with chronic diseases, obesity. If we lower the uric acid, treat these patients the risk will be reduced.  High uric acid elevates the risk while lower uric acid reduces the risk of major cardiovascular diseases.


Continuing Prof.Austin Stacks said that studies have shown that Hyperuricaemia elevates blood pressure. Treatment with Allopurinol lowers uric acid and lowers blood pressure. Speaking about the burden of disease in acute Hyperuricaemia Prof.Austin said that a study from United States has showed that co-morbidity is common in patients with Hyperuricaemia.  These patients are obese, suffer from chronic kidney disease, hypertension, and cardiovascular conditions. Uric acid not only causes gout but it also causes hypertension, kidney disease, diabetes mellitus and metabolic syndrome. There is a biological proof for that. Treatment with Febuxostat lowers uric acid and alleviates systemic hypertension.


Hyperuricaemia Advisory Council organized the First International Hyperuricaemia Summit in Pakistan last month.
Group photograph taken during the summit at Karachi on March 21, 2017 shows the Guest Speaker Prof. Austin
Stack from Ireland along with the some of the participants and those who took part in the poster competition.

Speaking about epidemiological evidence he pointed out that uric acid was a risk for new onset of hypertension. There is link between hypertension and Type2 diabetes. Patients with high uric acid have high risk of developing diabetes mellitus. As a Nephrologist I know that lowering the uric acid protects the kidney. High uric acid is also a risk for new onset of chronic kidney disease. Patients with high uric acid have high risk of death from cardiovascular disease. In fact high uricaemia is a significant independent risk factor for death from cardiovascular disease. It has changed clinical Guidelines in many developed countries. Lowering uric acid is linked with major events reduction. If left untreated it affects progression of kidney disease.


Kidney function Prof.Austin Stacks opined declines after the age of fifty years. Hypertension and diabetes accelerates it. Lower uric acid will protect the kidney function. Treatment with Allopurinol lowers uric acid and it also lowers blood pressure. It also leads to significant reduction in CVD events in chronic kidney disease.  Studies have also shown that Febuxostat lowers uric acid in chronic kidney disease after six months treatment. It also protects kidney function and prevents further deterioration. Allopurinol also reduces risk of kidney failure. It has greater protective effect on kidney disease.  Urate lowering therapy prevents kidney failure as shown in a US study, he added.

He summed up his presentation by stating that uric acid levels raise cardiovascular risk. Better control if Urate levels are <6mg/dl. Lowering uric acid stabilizes kidney function and prevents decline in GFR. Lowering uric acid is also associated with less kidney failure.


Prof. Austin Stacks Consultant Nephrologist from Ireland photographed with some of the participants to the meeting
organized by HAC at Rawalpindi on March 24, 2017.

Earlier Prof. Waris Qidwai Chairman Dept.of Family Medicine at Aga Khan University presented details of his study regarding frequency of uric acid levels in Pakistani general population. Hyperuricaemia, he said, was a risk factor for myocardial infarction and stroke. Studies have also shown that it is also a risk factor for chronic kidney disease. Global prevalence of Hyperuricaemia shows that it increases with increase in age. It is more common in men but it is rare in pre-menopausal women. Total number of patients enrolled in this study was 2727 which included 1320 male and 1407 female. Their average age was 43 years. This study showed that 51% of women and 29% of men had Hyperuricaemia.  The co morbid diseases in this population included hypertension in 32%, Diabetes in 36%, CKD in 5% and obesity in 18%.  Almost 37% of patients reported with symptoms of joint pain, 8% had single joint pain while 58% had multiple joint pains and 18% had kidney stones. His conclusions were that prevalence of Hyperuricaemia in Pakistan was alarming compared to the rest of the world. It was essential that physicians regularly screen for uric acid levels in patients with co-morbidities. Physicians should also be taught to treat asymptomatic Hyperuricaemia as well as according to the latest Guidelines.

Dr. Masood Jawaid Director Medical Affairs in PharmEvo speaking at the occasion stated that Mission of Hyperuricaemia Advisory Council is to improve prevention and care of Hyperuricaemia and its co morbid conditions in Pakistan by increasing physicians and public awareness.  To achieve this objective we have organized Digital Course, organized Free Uric Acid Camps, and organized CME meetings. Our goals include raising awareness of the burden and adverse clinical consequences of Hyperuricaemia through CME, review evidence that has linked Hyperuricaemia with major chronic diseases. It also includes demonstrating the efficacy of Urate lowering therapies in reducing Urate levels, preventing gout flares and modifying cardiovascular and renal risks. We also wish to promote development of clinical guidelines for Hyperuricaemia and Gout management.  During the last one year we have organized 142 events, prepared Digital Course in collaboration with University of Health Sciences. Thirty free uric acid camps were organized. We have also organized   a poster competition in which eighteen posters were submitted and their abstracts have been published as a special supplement of Pakistan Journal of Medical Sciences.

Dr. Faizan Shaukat Manager Medical Affairs in PharmEvo gave details of the Digital Course which is titled as Uric Acid Reduce the Excess. This is an interactive scenario based learning with a Quiz programme. Those who get 70% marks get a CME certificate from University of Health Sciences.

 

Syed Jamshed Ahmad Chief Operating Officer PharmEvo, Prof. Nighat Mir,
Dr. Masood Jawaid and others photographed along with Prof. Austin Stacks
during the meeting held at Lahore on March 22, 2017.

During the discussion Prof. Austin Stacks said that there are many treatment strategies for lowering uric acid including the use of Allopurinol and Febuxostat. One of the participants asked that once a patient is diagnoses to be suffering from Gout, after treatment for how long one should continue maintenance therapy? To this, Prof. Austin said that it is usually for life long. You treat gout, stop therapy, pain comes back, and hence it needs long term treatment. Responding to another question Prof. Austin said that he will take detailed history, look for symptoms of gout and kidney impairment. If positive, I will treat such patients to prevent diabetes. One of the participants opined that if one can control uric acid with diet, do we still need drug therapy to which he responded that you might have an exceptional patient.


Yet another participant stated that uric acid is not a risk for MI but it leads to hypertension which then leads to MI. Prof. Austin said that studies have shown that uric acid is an independent risk for hypertension but there is also link between high uric acid and MI. Meta-analysis have shown this. It can be a direct myocardial infarction or because of hypertension, it works both ways. Asked about the efficacy of Allopurinol and Febuxostat, Prof. Austin Stacks said that Febuxostat is most potent and it also has no need for dose reduction with kidney function. He further stated that it requires lifelong treatment but we have no long term studies. It is important for the physicians to decide about it. One of the participant said that he had a patient with normal kidney, not diabetic but his high uric acid is not coming down with even high dose of Febuxostat? Prof. Austin remarked that these are patients who are resistant to Febuxostat. In such cases you need to increase uric acid secretion. Some of the posters presented have shown that high uric acid is linked with excessive use of red meat but how it is caused, we do not know the final answer. Answering a question Prof. Waris Qidwai said that his was just a prevalence study and they did not look for any intervention strategies. Now they plan to do that. Prof. Austin said that Prof. Waris Qidwai’s study has shown a prevalence of 28% which is quite high. Role of diet in uric acid is still not clear but we all know that dietary restrictions are very difficult to practice. 


Prof. Austin Stack along with Prof.Waris Qidwai and Mr.Shaukat Ali Jawaid inspecting the posters submitted for the
poster competition during
the First International Summit on Hyperuricaemia at CPSP Karachi on March 21, 2017.

There may be some role of genetics as well. The prevalence of Hyperuricaemia in Ireland, Prof. Austin Stack remarked was 20-25%. One of the participants said that they were told that use of four lemons a day takes care of Hyperuricaemia. At this Prof. Austin said that this claim has got to be scientifically tested. Maintenance therapy will depend on individuals. It is important that one keeps to the target then irate the dose to tolerance level. The meeting at Lahore was organized on March 22, 2017 while at Rawalpindi and Islamabad the meetings were held on March 24, 2017.

Poster Competition

 All the posters submitted in the competition were judged by experts. The entries were divided into three groups i.e. seniors healthcare professionals, junior doctors and nurses, medical students. The first prize in this poster competition was won by Dr. Humaira Rasheed (Apolipoprotein B (Apo B) and Very Low-density Lipoprotein (VLDL) are emerging risk factors for Hyperuricemia and Gout) Second prize went to Muhammad Sami (Prevalence of risk factors of hyperuricemia in Pakistani Population) while third prize was won by Hina Liaquat (Patient’s Knowledge, Awareness, management& Preventive strategies towards gout: A survey Based study In Asian Population.

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