REFERENCE CASE — A REAL-WORLD JOURNEY FROM VIEN GUT (HO CHI MINH CITY, VIET NAM)

Reference case: A real-world example from Vien Gut (Ho Chi Minh City, Viet Nam)

To illustrate the feasibility of unblocking the bottleneck at the guideline tier and the mandatory foundational chain—especially for patients with severe complicated gout with complex chronic multimorbidity—we briefly share the real-world journey of Vien Gut. This is only a local case from a middle-income country, not the only model and not a perfect model, offered purely as a reference example for debate.

1) Starting point (2007): the hardest patient group

Vien Gut began in 2007 by serving the most difficult patient group: severe complicated gout with complex chronic multimorbidity (large tophi, chronic kidney disease, cardiovascular disease, diabetes, etc.), whose main wish was simply to stop recurrent acute inflammatory joint pain.

From 2007–2014, Vien Gut did not yet have access to EULAR 2006 or ACR 2012, and Viet Nam’s Ministry of Health only issued national gout treatment guidance in 2014. Therefore, the model during that period focused on helping patients manage acute inflammation and pain flares, and did not yet apply urate-lowering therapy (ULT) systematically to lower serum urate.

Although a combined approach—anti-inflammatory/analgesic medications, nutritional interventions, and adjunct supportive measures using natural compounds with many preclinical studies worldwide—helped severe patients control acute flares better, the absence of systematic ULT meant the root cause (hyperuricemia) was not controlled. As a result, flares still recurred frequently, the disease progressed, and overlapping complications became increasingly difficult to manage.

2) Turning point (2014): mechanism-based approach + OMERACT ultrasound as a feasible verification tool

In 2014, a research collaboration with Professor Thomas Bardin (co-author of EULAR 2006) helped complete the crystal-mechanism-based approach and adopt OMERACT-standardized musculoskeletal ultrasound as a feasible verification tool (without requiring expensive DECT).

3) 2014–2024: operational success, but a persistent bottleneck — maintaining lifelong ULT after “no pain”

From 2014–2024, the operational layer achieved clinical cure (no recurrent flares) even in severe complicated patients. However, one major difficulty persisted: convincing patients to maintain lifelong ULT after pain stops.

The reason is the same paradox described by Professor Bardin and many experts: being trapped in “curable in principle”—waiting for large confirmatory “cure proof” studies before formally codifying the goal, even though real-world practice had already observed many patients becoming crystal-free (no urate deposits detectable).

4) 2024: the decisive trigger — patients demanded “certification” if they were truly cured

In 2024, when convincing some patients who had become crystal-free that they were “cured” and must maintain lifelong ULT to avoid relapse, patients asked back:

“If you say it’s cured, why don’t you certify that we’re cured? If you certify it, we will comply.”

This triggered a decisive decision: Vien Gut, together with Professor Thomas Bardin, internally unblocked the cure goal (not communicated publicly) and built:

  • Guidance documents for physicians and multidisciplinary teams

  • Guidance documents for patients

  • A requirement that patients commit to lifelong ULT maintenance

  • A signed commitment between Vien Gut and patients to pursue the cure goal for all treated patients (condition: no allergy to urate-lowering drugs and adherence to treatment)

5) Raising OMERACT remission into “conditional gout cure” — definition and framework

At the same time, Vien Gut “raised the ceiling” of OMERACT remission criteria into a Conditional Gout Cure standard, based on the following:

5.1) What does “raising the ceiling” mean?

In the gout context, “raising the ceiling” means:

  • Keeping all internationally recognized remission conditions (OMERACT 2016 and the simplified G-CAN 2024/2025 version) as the mandatory minimum foundation; and

  • Adding a higher tier to confirm the mechanistic destination of gout: the body is crystal-free at the time of assessment, rather than merely “clinically stable.”

In other words: remission is “stable,” while conditional gout cure is “crystal-free at assessment,” but does not mean permanently cured.

5.2) Context: remission is the most important “measure,” but does not yet reach the mechanistic destination

Remission criteria are the most important measure to evaluate long-term stability in gout follow-up. Two key milestones are recognized globally:

OMERACT 2016 (initial – 5 domains):
sUA ≤ 6 mg/dL; no tophi; no acute flares; pain ≤ 2/10; PGA < 2/10.

G-CAN 2024/2025 (simplified – 3 criteria):
sUA < 6 mg/dL; no acute flares; no subcutaneous/palpable tophi.

Shared limitation: both mainly stop at clinical remission and do not directly assess intra-articular crystals, the central disease entity of gout. Therefore, raising the ceiling requires integrating OMERACT-standardized joint ultrasound to move toward conditional gout cure.

5.3) Comparison table — remission vs conditional gout cure (ceiling-raised)

Criterion Remission (OMERACT 2016) Remission (G-CAN 2024/2025) Conditional Gout Cure (Ceiling-Raised)
Serum urate (sUA) ≤ 6 mg/dL (≥2 times/12 months) < 6 mg/dL (≥2 times/12 months) ≤ 6 mg/dL (maintained stably throughout 12 months)
Tophi / crystals None (clinical exam) None (subcutaneous/palpable) Structural clearance: no crystal coating on cartilage surfaces and no tophi in all hand/foot joints (including joints that have never been painful), verified by ultrasound
Acute gout flares None within 12 months None within 12 months None within 12 months
Pain ≤ 2/10 Removed (simplification) No pain at all, even minimal. If persistent dull pain remains, another cause must be investigated (OA, chronic damage, etc.) and not attributed to urate crystals
Global (PGA) < 2/10 Removed (simplification) Ceiling-raised: the body is completely normal with respect to gout

5.4) Core meaning of “conditional cure”

  • Cured at the time of assessment: when ultrasound confirms no remaining crystal deposition, the patient no longer meets diagnostic criteria for gout and is verified as cured at assessment.

  • Not permanent cure: this is a conditional state.

5.5) Maintenance conditions and relapse prevention

Because causes of hyperuricemia (constitution/genetics/underlying diseases) remain, if lifelong ULT is not maintained:

  • sUA rises again

  • crystals re-deposit

  • gout relapses

5.6) Feasibility of lifelong therapy after achieving conditional cure

Maintaining urate-lowering medication after achieving conditional cure is easier because:

  • the body is crystal-free

  • there is no longer flare risk driven by active crystal dissolution

  • patients no longer need long-term prophylactic anti-inflammatory/analgesic drugs (colchicine, NSAIDs, corticosteroids), which carry significant adverse effects

5.7) Why DECT is not included as a mandatory criterion

Although DECT may be more sensitive overall, Vien Gut chose ultrasound because:

  • it is feasible to deploy broadly (low cost, convenient, no radiation)

  • it can be more sensitive in early-stage disease

  • OMERACT has standardized ultrasound lesions and demonstrated responsiveness for monitoring ULT

  • it fits longitudinal outpatient follow-up

6) Rationale for raising the ceiling in this direction

  • Mechanistic rationale: gout is a crystal-driven disease; when crystals are absent, the disease entity is removed at the time of assessment.

  • Gap in remission: current criteria reflect clinical stability but do not confirm structural clearance in joints.

  • Appropriate verification tool: OMERACT ultrasound is feasible to verify deposition and track dissolution under ULT.

  • Vien Gut real-world basis: longitudinal follow-up has been implemented; ultrasound is used to verify crystal-free status and confirm “cured at assessment,” with clear communication that this is not permanent cure.

7) Benefits of raising the ceiling

  • Ending ambiguity: instead of “living with the disease,” physicians can state “cured at this timepoint,” based on ultrasound evidence of crystal clearance.

  • Shifting adherence: patients accept one daily urate-lowering pill as protecting the cure achievement, rather than taking medication under fear of pain recurrence.

  • Optimizing cost and health: reducing and moving toward eliminating long-term anti-inflammatory/analgesic drugs.

  • Shifting public mindset: moving from “chronic disease cannot be cured” to a conquest mindset focused on crystal clearance.

  • Shifting research and guideline systems: encouraging research designs to move from “index management” to “proving structural clearance.”

  • Scientific communication spillover: creating positive scientific communication that gout can be cured in real practice—meaning cured at assessment and maintained by preservation therapy.

8) Initial results and reactions

  • 151 patients (mostly severe complicated cases) received a gout cure certificate; all committed to lifelong ULT.

  • 95 patients reached scheduled periodic reassessment: 90 returned and continued ULT; ultrasound showed no re-deposition and no relapse of inflammatory pain.

Positive patient response: after receiving the certificate, patients were highly motivated, shared the outcome with family and friends, and many guided other patients to come to Vien Gut for treatment. They found it easier and lighter to maintain urate-lowering therapy than to use long-term prophylactic anti-inflammatory/analgesic drugs. Patients still in treatment gained strong motivation when they watched the certificate ceremony.

Not positive response from some musculoskeletal specialists: some specialists wrote letters questioning Professor Thomas Bardin: “On what basis can you say gout can be cured?” This reflects the paradox of awareness despite the principle being clear in guidelines for 20 years.

This case illustrates: even at a local scale with limited resources, naming the cure goal (even internally) + raising the ceiling standard + clear communication can resolve the biggest adherence barrier—especially in complex patients.

9) Invitation for other centers’ reference cases

We share this as a reference example and invite the community to share similar real-world cases from other centers worldwide.

Have you experienced that naming the cure goal improves real-world practice?