Monday, 18 Nov 2019

You are here

Time to Rethink Gout as a Chronic Disease

The current issue of JAMA has a perspective article on Gout’s bad rap as dietary disease rather than the complex, chronic inflammatory disorder that is ineffectively treated in many. 

The author and experts interviewed believe that the pipeline of new drugs for gout will fuel the future of evidence-based care and more informed lifestyle instruction.

Gout affects about 4% of adults in the United States. The growing number of older adults, who are more likely to have gout, is expected to increase the need for gout care.

"The disease of kings" is clearly a misnomer as gluttony and excess seldom stand in the way of better care.  Sadly, many with gout fail to recognize it as a form of arthritis,  A 2016 online survey showed that 71% didn’t know gout and that half with gout were embarrassed by their condition. 

Although diet is often implicated, evidence proving the benefits of strict avoidance are limited.  While red meat, alcohol, sugar-sweetened soft drinks, and seafood have been implicated, the ACR guideline suggests that avoidance of purine-rich organ meats (liver), shellfish and sardines may only improve serum uric acid levels by10% to 18%.

Many experts have noted the limitations and pitfalls with found with a dietary approach to gout. 

A real problem are the differing treatment approaches and understanding of gout by primary care physicians (PCPs) and rheumatologist, exemplified by their contrasting guidelines. The 2012 ACR focuses on a a treat-to-target approach with the goal of a uric acid levels below 6 mg/dL and the use of urate-lowering medications long-term with frequent monitoring.  Yet the 2016 American College of Physicians guideline only has a treat-to-symptoms approach emphasizing the use of anti-inflammatory medications to control flares and reserving uric acid-lowering therapy for patients with frequent flares, 

Discrepancies between the guidelines may be hampering patient care, and hopefully upcoming meetngs between the ACR and ACP may resolve these differences. The ACR’s gout guideline is scheduled for release in 2020.

Emerging evidence suggests that a chronic disease care model for gout, which simultaneously addresses uric acid levels, lifestyle, and dietary factors, may improve management and outcomes for patients with gout.

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

T2T Lowers Mortality in Gout

A Spanish prospective cohort of active, uncontrolled gout patients were followed and showed that failure to reach a target serum uric acid (sUA) level of 6 mg/dl (0.36 mmol/L) or less was associated with a 2-3 fold increase in mortality.

Novel Inhibition of MSU Crystal Inflammation

Researchers from Washington State University have shown that inhibition of tumor growth factor-β (TGF-β)-activated kinase 1 (TAK1) can effectively downregulate inflammatory mediators and suppress inflammation caused by gout.

Monosodium urate (MSU) crystals directly activate the inflammasome to produce a plethora of pro-inflammatory cytokines, including interleukin-1β (IL-1β). 

Patients Prefer Nurse Led Care for their Gout

Despite the well known, well publicized treat-to-target (T2T) goal of a serum uric acid (SUA) level < 6 mg/dl, this goal is seldom achieved (< 40%) in clinical practice and patient adherence has been unacceptably low. A recent study shows that nurse-led care led to better outcomes in gout including patient acceptability, long-term adherence, and less flares.

Anakinra Use in Hospitalized Gout Patients

While the efficacy and safety of interleukin 1 (IL-1) inhibitors (e.g., anakinra) in the acute management of gout and pseudogout has been repeatedly shown, the cost efficacy of such biologic therapy has rendered it impractical for most. A new retrospective study has shown that IL-1 inhibitors may be effective and appropriate for some medically complex, hospitalized patients with acute gout or calcium pyrophosphate crystal arthritis.

Higher Rates of Venous Thromboembolism in Gout

A Canadian administrative claims analysis has shown that gout-associated inflammation increases the risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) before and after the diagnosis of gout.