QD Clinic: Can RA and Gout Manifest Simultaneously? Save

Hi, it's Dr. Janet Pope. This is a QD clinic talking about gout. So, this is entitled, can rheumatoid arthritis and gout manifest simultaneously? I hope you like this case and if you do, you can follow me as well at Janet Berdo on X.

So, this is a true case — a 54-year-old man with seropositive RA. In past, he was strongly seropositive and active. He had nodular erosive rheumatoid arthritis onset when he was 22 years old. He was stable on methotrexate and hydroxychloroquine for years as back then we didn't have advanced therapies. However, we will fast forward. So he's 54.

When he was 44, he lost his job. There was downsizing at his factory and he became a bit depressed. He said that he was getting more complaints recently of Achilles nodules and lumps on his toes. On exam he had what appeared to be tophi over some MTPs and on his toes proximally, and his first MTP on one foot was slightly chronically swollen. He denied any pink or red joints and none were pink or red today. Other joints are all excellent. So it was a swollen joint count of one.

So being the detective, I asked what's been going on. So he's had this poor mood. He hasn't been working for 10 years. He admitted to drinking 10 to 12 beers a day for probably the last eight or 10 years. He had a high uric acid level when I ordered it. And we certainly gave a lot of counseling about methotrexate and he did admit to being fairly non-compliant with methotrexate because he had been in remission with RA for years.

So the questions are: does he have RA? Is there a negative association between RA and gout, or is it actually contrary to what we were taught way back when — is it actually an increased association? And is beer worse than other alcohol?

So yes, he had RA for decades. I went back and confirmed his positive serology. I couldn't find old X-rays but we did new X-rays that showed a classic first MTP erosion. Old X-rays were reported but not viewable from years ago as having a small erosion at the styloid and second MCP on the radial side, which would go with RA, and RA was stable for years. So I'm concerned about his alcohol use and abuse and obviously his mood and the use of methotrexate.

So, is this gout? Yes. He's had a recent change in his status — heavy heavy alcohol use and very high uric acid. He has tophi and he's been a heavy drinker. His feet are involved and not other areas.

So, why would beer be causing worse problems? Beer is rich in purines. Consuming beer we know can worsen gout. So can other alcohols. But there is data that basically alcohol from beer is worse for gout, and it might be the yeast, it might be the amount of purine load and the fermentation — it's really hard to know. It's also the sugar content. So I did look it up. Beer has the highest purine content, and in wine and spirits it's low. The impact on uric acid for beer is far stronger than wine or spirits.

So we used to think that rheumatoid arthritis and gout did not coexist, or existed rarely. Why? RA more common in women — back in the day it was women of childbearing years, so premenopausal. Now our population is older and living longer. And also women back in the day drank less alcohol, and in general we advise against alcohol use, or certainly any moderate alcohol use, when people are taking methotrexate.

So what's different now is women are often onset perimenopausal in our early rheumatoid arthritis or CATCH cohort. The mean age of onset is 55. That's the same with the US cohort BRASS, and it's fairly similar in the UK, and in France it's early 50s. So it's a different age distribution. Our patients used to be mostly normal weight. Now the whole population has more metabolic syndrome, and two-thirds of our patients with rheumatoid arthritis in many studies — including our early arthritis study — two-thirds of our patients are overweight. So one-third obese, one-third overweight, one-third normal weight.

The other thing is our patients are getting more comorbid as they live longer. Hypertension is increased in patients with RA — probably two-thirds of RA patients over time will develop hypertension. Our guidelines say use diuretics as first line. There's more heart failure as they get older and more coronary artery disease. Starting aspirin might exacerbate gout, and also if not in steady state, going up and down on the doses. CKD is slightly increased in RA but also increased if using NSAIDs and from the comorbidities. Also, alcohol became fashionable in the baby boomers having their red wine — a drink a day — and it's going down again in usage, but that could increase gout.

The other thing is with metabolic syndrome, there's more SGLT2 use if they have concomitant type 2 diabetes. SGLT2 inhibitors act like allopurinol — they break down purines, so you get more gout before you can get less gout over time. Also maybe there's misclassification because we have more seronegative RA, about 30 to 40%, in many
early RA cohorts, and it can present as pseudo-RA. So what about the frequency of gout in RA? So there are some studies — there's a study out of Korea, a population cohort, and they found that gout was almost three-fold higher in RA than the general population, age and sex matched. Similar from Israel, it was about a double prevalence compared to non-RA patients. So we have a large rheumatoid arthritis registry, the Ontario Best Practice Research Initiative, or OBRI. So almost 3,600 patients, 113 with gout plus RA. And how are they different, the gout plus RA patients? They're more common in men. So women are overall about 79%, whereas it's only 52% women in the gout group. They're older. The gout patients on average in a prevalent cohort were 66 years old. The other RA patients were 58 years old. And not surprisingly, they had more metabolic-type problems — cardiovascular disease, diabetes, hypertension — and they were 1.8 times more likely to be obese.

So what are the take-home messages? Gout can coexist in RA. It's approximately 3% of our prevalent RA population. There's more of the traditional risk factors in those who have gout. And there's a little bit more glucocorticoid use in those who have concomitant gout, and that might be because they have two kinds of inflammatory arthritis instead of one. Address the comorbidities, but think of safe treatments if your patient with RA does have gout.

I hope you enjoyed watching our program on so many topics, including gout this month. Thank you.