Interview: Prof. Austin Stack from Ireland


 Interview: Prof. Austin Stack from Ireland

Management of Hyperuricemia and Gout:

Gout patients can continue taking Low Dose
Aspirin therapy to get protection from cardiac diseases

KARACHI: Prof. Austin G. Stack, MD Professor and Chair of Medicine, University Hospital Limeirck from Ireland recently visited Pakistan on an invitation from PharmEvo Pharmaceuticals.  He was the guest speaker at a series of symposia organized by the company at Karachi, Lahore and Rawalpindi-Islamabad besides chairing an Experts session at Karachi where diagnosis and management of Hyperuricemia and Gout were discussed in detail. In his presentations at these symposia he talked about various Guidelines and shared his knowledge and experience of managing Hyperuricemia and Gout with drug therapy in the light of recent studies. During his stay at Karachi, he spared some time to talk to “Pulse International” Chief Editor Mr.Shaukat Ali Jawaid. Given below are the excerpts from the conversation:

Prof. Austin Stack

For the management of Hyperuricemia and Gout we have these American College of Rheumatology Guidelines, Japanese and Philippines Guidelines and then NICE guidelines. Do we really need to have so many guidelines and what is the difference in these guidelines if any?

There is not much difference in these guidelines. Previously it was the national guidelines but now there is emphasis on having international guidelines. The idea is to have a consensus.  Every Committee or Board has its own view point. Historically there is difference between American and European guidelines. General principle is to achieve consensus. All these committees and Boards look at the same evidence but the way they interpret is different. At present there is consensus on almost 80-90%.

Would you like to add anything on drug therapy for Gout treatment?

Xanthine Oxidase Inhibitors are underused in treatment of Gout.  Alloupurinol is rarely prescribed at its maximum dose. Febuxostat is a non-purine inhibitor of Xanthine Oxidase. Its efficacy is dose dependent in decrease of uric acid levels. Febuxostat is more potent than Alloupurinol and it is also safe in patients with chronic kidney disease in stage one to three. Studies have shown that Febuxostat is better than Alloupurinol in getting uric acid <6mg/dl.

For treatment of Gout, Hyperuricemia guidelines are the same for diagnosis, management and the treatment strategies. There are some minor differences. The Group which has just met may have latest information than those who met some time ago.  Those who have just met have more update data and information.

In your presentation you talked about avoiding the use of Thiazide and loop diuretics for the treatment of hypertension but these are very effective anti-hypertensive’s and also cost effective.

Non-Steroidal Anti-inflammatory Drugs  (NSAIDs) are very good for pain relief and inflammation but they are not good to be used for patients suffering from peptic ulcer. Hence, in such situations we have to look for alternatives. Every patient is different. Different patients have different conditions. They will have different treatment. We need many things for all groups of patients. Thiazide and loop diuretic are no doubt very effective anti-hypertensive drugs and they are also economically priced but they are not for every patient suffering from high blood pressure. Hence, for patients suffering from Gout or elderly drugs like Losartan potassium, captopril or Enalapril are preferred as they are effective in treating Hyperuricemia and gout complicated by hypertension because of their combined hypotensive and uricosuric effects.

You also mentioned that Aspirin should be avoided in patients suffering from Hyperuricemia but most of these patients are elderly and use of low dose Aspirin therapy provides protection against Cardiovascualr diseases. By avoiding Aspirin they will have increased risk of AMI and other cardiovascular diseases.

There is no doubt that Aspirin is a heart protector. It is also effective in preventing many cardiovascular events.  Patients suffering from Gout can continue to take Low Dose Aspirin therapy to get protection against heart diseases.  Urate Lowering Therapy (ULT) should be continued in such patients.

What is the role of Plain X-ray and CT or MRI in the diagnosis of Gout?  Do they offer any additional benefits?

Most Gout patients are diagnosed on clinical conditions, history and uric acid findings. CT or MRI may be helpful in detecting the disease in an early stage but these are not available easily. Hence, we need to look at the healthcare system in different countries.

Elderly patients have lot of co-morbidities and they are already taking many other drugs. Do we need to be more careful while managing these patients if they also have Hyperuricemia and gout?

Treatment strategy for Hyperuricemia and Gout is the same and Urate Lowering Therapy is indicated in all such patients if need be. If the patient has  more than two attacks per year or one attack and also suffers from Gout, has chronic gout, chronic kidney disease. All these patients should be treated and it forms a significant population. Prevalence of Hyperuricemia and gout is almost the same in UK and USA which is about 4%.

Who should be treating Gout? Is it the orthopaedic surgeon, internal physicians, rheumatologists, nephrologists or the primary care physicians?

Every healthcare professional that has the knowledge can treat these patients. We have to demonstrate, educate and disseminate the information regarding clinical practice guidelines on management of Gout. Public as well as healthcare providers all needs to be educated. Orthopaedic surgeons, rheumatologists and nephrologists all have a role to play but the role of primary care physicians is most important. Since they are easily accessible, these PHC physicians should be the main focus of any CME activity as regards management of Gout.

In your presentation you did not mention at all the role of complementary medicine in managing Hyperuricemia and gout despite the fact that literature mentions about the oral complementary agents for the treatment of an acute attack like cherry juice or its extract, salicylate-rich willow-bark extract, ginger, charcoal, strawberries, blak currant, sour cream, olive oil etc.

We have documented things which work on basics. Meta analysis shows that there are various things which work in gout. But where is the evidence for complementary medicine and unless there is evidence, I won’t recommend to use it. Instead I will ask for therapy which works and which has proven that it works.

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