Tuesday, 19 Mar 2019

You are here

Gout and the Social Determinants of Health

Sir Michael Marmot is one of my medical heroes. Despite appearing to be the epitome of British establishment medicine, in fact he was raised in Australia and received his medical degree from the University of Sydney, so we like to claim him as one our own.

He is best known for his work as a pioneer in the field of the social determinants of health. This began with his seminal work on the Whitehall study, which tracked mortality among public servants in the UK and, to everyone’s surprise, did not find an excess of cardiovascular deaths among the highly stressed upper strata of the workplace hierarchy, but instead showed a robust inverse linear association between mortality and position in the social hierarchy. The higher you are in the social structure, the less likely you are to suffer from chronic disease and premature death. Importantly, this association was found in a relatively affluent population, where material deprivation was not a concern, and suggests that social factors are fundamental upstream drivers of a variety of health-related behaviours and experiences that are primarily responsible for the distribution of chronic disease within society - or what Marmot has termed the “causes of the causes”. Such as association has since been confirmed in a variety of different social contexts and for a wide range of chronic disease states. Striving to achieve good health, then, is the province not just of the individual, but also of society and the policy-makers who influence its structure.

“The stark fact is that most disease on the planet is attributable to the social conditions in which people live and work.”
Stonington & Holmes, PLoS Medicine 3(10):1661(2006)

During a fascinating gout session on October 21, Hyon Choi presented an important paper (abstract 874) which used data from the Health Professionals Follow-up Study to try to understand the rapid increase in the incidence of gout in recent decades. Data from over 44,000 men in the HPFS demonstrated that five factors (BMI, diet, diuretic use, alcohol consumption, and vitamin C supplementation) accounted for 80% of the population attributable risk of incident gout. In other words, if we could eliminate poor diet, obesity, and alcohol use, we could largely prevent incident gout. Clearly this is a goal best addressed at the social level rather than the individual level - it is not so much the individual’s decisions about diet and alcohol that is important in the population, but much more the structures that influence these decisions: the “causes of the causes”. Gout is not just a highly-treatable disease, it is potentially highly-preventable. For me, this paper is a call to action both for rheumatologists and for our politicians and policy-makers. Or, in the prescient words of the great Rudolf Virchow:

“Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution”

Add new comment

More Like This

Ironwood Retreats from the US Gout Market

Ironwood Pharmaceuticals discontinued the marketing and sales of both lesinurad (Zurampic) the combination drug of lesinurad and allopurinol (Duzallo) in the United States effective February 1, 2019. In addition the Duzallo and Zurampic Patient Savings Program were also discontinued on December 31, 2018.

The company stated that this was a financial decision unrelated to the efficacy or safety of lesinurad.

Allopurinol Reduces Cardiovascular Outcomes in Diabetes

A Canadian study has shown that elderly diabetics who take allopurinol have a significant reduction in cardiovascular outcomes.  

Hyperuricemia has been shown to be a biomarker for cardiovascular outcomes in multiple disorders. These investigators studied the effect of allopurinol and mortality on CV outcomes in a population-based retrospective cohort study from Ontario, Canada.

FDA Slaps a Boxed Warning on Febuxostat for CV Risk

The U.S. Food and Drug Administration (FDA) has reviewed data from the Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) trial and concluded there is an increased risk of death with Uloric (febuxostat) compared with allopurinol, and has added this as a boxed warning to the drug’s product label.

U.S. Gout Rates Remain Steady, but Substantial

Using data from 5,467 adults in the US in the National Health and Nutrition Examination Survey (NHANES) for the years 2007-2016, researchers found that the prevalence of gout and hyperuricemia has remained at 3.9%, having doubled from the 1960s to the 1990s, corresponding to an estimated 9.2 million adults with gout in 2015-2016.

Febuxostat Gets Reprieve from FDA Advisory Panel

On January 11, 2019 the FDA convened two advisory panels (the Arthritis Advisory Committee [AAC] and the Drug Safety and Risk Management Advisory Committee [DSaRM]) to consider the cardiovascular safety of febuxostat (Uloric) based on the 2018 “Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) study. 

The Vote