Gout and the risk of type 2 diabetes among men with a high cardiovascular risk profile

Epidemiology of gout: an update

Gout is the most common inflammatory joint disease in men, characterised by formation of monosodium urate (MSU) crystals in the synovial fluid of joints and in other tissues. The epidemiology of gout provides us with the understanding of the disease distribution and its determinants. In an attempt to update the knowledge on the topic, more recent research reports on the descriptive epidemiology of gout are reviewed in this article. The review describes clinical characteristics and case definitions of gout, including the Rome and New York diagnosis criteria of gout, '1977 American Rheumatism Association (ARA) criteria' and the 10 key propositions of the European League Against Rheumatism (EULAR) recommendations. Gout incidence, prevalence, morbidity and mortality, geographical variation of the disease, relevant risk factors for both the occurrence and outcome of gout and trends of the disease over time are then described. Difficulties in obtaining the information and data reported are also discussed.

The epidemiology of uric acid and fructose

During the past few decades, the mean serum uric acid levels and the prevalence of hyperuricemia in the general population appear to have increased. Correspondingly, the prevalence and incidence of gout have doubled. Potential reasons behind these trends include the increasing prevalence of obesity and metabolic syndrome, Western lifestyle factors, increased prevalence of medical conditions (eg, renal conditions, hypertension, and cardiovascular disorders), and use of medications that increase uric acid levels (eg, diuretics and low-dose aspirin). The substantial increase in sugar-sweetened soft drinks and associated fructose consumption also has coincided with the secular trend of hyperuricemia and gout. Recently, several large-scale epidemiologic studies have clarified a number of these long-suspected risk factors in relation with hyperuricemia and gout. Furthermore, recent studies have illuminated the substantial comorbidities of hyperuricemia and gout, particularly metabolic-cardiovascular-renal conditions. Although many prospective studies have suggested an independent association between serum uric acid levels and the future risk of cardiovascular-metabolic morbidities and mortality, only a limited number of randomized clinical trials and observational studies recently have shown that the use of allopurinol can be beneficial against these outcomes. Because these data are scarce and the effects of allopurinol might not be limited to decreasing serum uric acid levels, the potential causal role of uric acid on these outcomes remains to be clarified with further studies.

Rheumatic manifestations of diabetes mellitus

DM is associated with various musculoskeletal manifestations. The strength of this relationship varies among the various musculoskeletal disorders; the associations are based mostly on epidemiologic data. For most of these conditions, definitive pathophysiologic correlates are lacking.Hand and shoulder disorders occur more frequently than other musculoskeletal manifestations of DM. Recognition of the association between DM and shoulder adhesive capsulitis, DD, and stenosing flexor tenosynovitis facilitates their correct diagnosis in the setting of DM and prompt initiation of appropriate treatment, which may include optimizing glycemic control. Conversely, awareness and identification of the characteristic musculoskeletal manifestations of DM may facilitate earlier diagnosis of DM and initiation of glucose-lowering therapy to retard the development of diabetic complications.Much less has been published about the musculoskeletal complications of DM than about its micro- and macrovascular complications. Prospective case-control cohort studies are needed to establish the true prevalence of musculoskeletal complications of DM and the metabolic syndrome, especially in this era of tighter glycemic control.The potential relationship between DM and the development of OA needs to be clarified in large, prospective, case-control cohort studies. The effect on musculoskeletal manifestations of various therapeutic regimens to manage DM should be studied prospectively. Treatment regimens for some musculoskeletal conditions associated with DM, such as DISH, should be studied in larger prospective, randomized,controlled clinical trials.At the molecular level, further studies are warranted to clarify the potential contribution of AGEs and adipokines to the development of OA and diabetic musculoskeletal syndromes, such as shoulder adhesive capsulitis, DD, stenosing flexor tenosynovitis, and LJM. Identification of such molecular targets for therapy would promote the development of additional treatments for these and other rheumatic diseases.

Elevated risk of mortality among gout patients: a comparison with the national population in Taiwan

OBJECTIVES

Accumulating evidence suggests that gout is associated with increased overall and cardiovascular mortality. Using data from a large consecutive cohort of gout sufferers who were followed for 8 years, we investigated mortality among gout sufferers and compared the results with data from the general population of Taiwan.

METHODS

The study comprised 6631 people who had gout diagnosis at outpatient department of the Chang Gung Memorial Hospital in 2000. Survival status and cause of death were ascertained by examining the National Death Registry of Taiwan through 2008.

RESULTS

During 53,048 person-years of follow-up in 6631 gout patients, 1273 (male, 941; female, 332) deaths were identified, corresponding to the crude mortality rate was 21.3 (male, 20.0; female, 26.1) per 1000 patient-years, which was significantly higher than that of the national population. As compared with the national population of Taiwan in 2000, the all-cause standardized mortality ratio (95% confidence interval) was 1.29 (1.21-1.37) for men and 1.70 (1.53-1.89) for women. Both men and women in this cohort had higher standardized mortality ratios for death due to kidney diseases (men, 3.10; women, 3.54), endocrine and metabolic diseases (men, 2.24; women, 2.71), and cardiovascular diseases (men, 1.58; women, 1.81). Multivariate Cox regression showed no difference in mortality between genders.

DISCUSSION/CONCLUSIONS

Individuals with gout have increased mortality risk in both sexes; however, the extent of risk increment is higher in women. Kidney diseases, endocrine and metabolic diseases, and cardiovascular diseases are primary causes of death.

Elevated serum uric acid predicts impaired fasting glucose and type 2 diabetes only among Japanese women undergoing health checkups

AIM

This study assessed whether or not elevated serum uric acid can predict impaired fasting glucose (IFG) and type 2 diabetes mellitus (T2DM) in Japanese people undergoing health checkups.

METHODS

Altogether, 7114 male and 5529 female participants in both 2000 and 2005 were targeted for the study. After excluding those with IFG and T2DM, multiple logistic-regression analyses of 6408 men and 5309 women-average ages 48.4±10.2 and 50.0±9.1 years, respectively-were performed to identify independent risk factors for newly diagnosed IFG and T2DM in 2005, after adjusting for age, parental history of diabetes, body mass index (BMI), elevated blood pressure or hypertension, fatty liver, hypertriglyceridaemia, alcohol consumption and smoking status.

RESULTS

Prevalence rates for IFG and T2DM, and values for BMI, systolic and diastolic blood pressure, fasting blood glucose and triglycerides, showed significantly increasing trends in relation to serum uric acid quartiles in both genders. IFG and T2DM were newly diagnosed in 8.1% of men and 4.0% of women in 2005. Using multivariate models, the highest quartile of serum uric acid and increases in serum uric acid were independent risk factors, but only in women. Serum uric acid was not a risk factor in men when categorized by the cut-off values of 4.8 mg/dL, the limit for the highest quartile in women, and of 7.0 mg/dL.

CONCLUSION

Elevated serum uric acid predicted IFG and T2DM only in Japanese women undergoing regular health checkups.

Risk factors for gout and prevention: a systematic review of the literature

PURPOSE OF REVIEW

Our objective was to perform a systematic review of risk factors and prevention of gout. We searched Medline for fully published reports in English using keywords including but not limited to 'gout', 'epidemiology', 'primary prevention', 'secondary prevention', 'risk factors'. Data from relevant articles meeting inclusion criteria were extracted using standardized forms.

RECENT FINDINGS

Of the 751 titles and abstracts, 53 studies met the criteria and were included in the review. Several risk factors were studied. Alcohol consumption increased the risk of incident gout, especially beer and hard liquor. Several dietary factors increased the risk of incident gout, including meat intake, seafood intake, sugar sweetened soft drinks, and consumption of foods high in fructose. Diary intake, folate intake, and coffee consumption were each associated with a lower risk of incident gout and in some cases a lower rate of gout flares. Thiazide and loop diuretics were associated with higher risk of incident gout and higher rate of gout flares. Hypertension, renal insufficiency, hypertriglyceridemia, hypercholesterolemia, hyperuricemia, diabetes, obesity, and early menopause were each associated with a higher risk of incident gout and/or gout flares.

SUMMARY

Several dietary risk factors for incident gout and gout flares are modifiable. Prevention and optimal management of comorbidities are likely to decreased risk of gout. Research in preventive strategies for the treatment of gout is needed.

Prevalence of contraindications and prescription of pharmacologic therapies for gout

BACKGROUND

Patients with gout have comorbidities, but the impact of these comorbidities on treatment has not been studied.

METHODS

A total of 575 patients with gout were stratified according to certainty of diagnosis according to International Classification of Diseases, 9th Revision, Clinical Modification code alone (cohort I), American College of Radiology criteria (cohort II), and crystal diagnosis (cohort III). Comorbid conditions were defined according to International Classification of Diseases, 9th Revision, Clinical Modification codes, and stratified as either moderate or severe. Drug contraindications were defined as moderate or strong, based on Food and Drug Administration criteria and severity of disease.

RESULTS

The most common comorbidity was hypertension (prevalence 0.89). The presence of comorbidities resulted in a high frequency of contraindications to approved gout medications. More than 90% of patients had at least 1 contraindication to nonsteroidal anti-inflammatory drugs. Many patients demonstrated multiple contraindications to 1 or more gout medications. Frequently, patients were prescribed medications to which they harbored contraindications. The prevalence of patients prescribed colchicine despite having at least 1 strong contraindication was 30% (cohort I), 37% (cohort II), and 39.6% (cohort III).

CONCLUSION

Patients with gout typically harbor multiple comorbidities that result in contraindications to many of the medications available to treat gout. Frequently, despite contraindications to gout therapies, patients are frequently prescribed these medications.

Functional and biomechanical characteristics of foot disease in chronic gout: A case-control study

OBJECTIVES

despite the predilection of gout to the feet, the impact of gout on foot function and biomechanics is currently unknown. The aim of this study was to describe the effects of chronic gout upon function and selected biomechanical parameters associated with gait.

METHODS

twenty-five patients with a history of gout were compared with 25 age and gender matched control participants with no history of gout or other forms of arthritis. General function, foot specific disease activity and lower limb activities were determined using the Health Assessment Questionnaire, Foot Function Index (pain domain), and Leeds Foot Impact Scale respectively. Each patient also underwent a gait assessment that included plantar pressure measurements and an evaluation of temporal-spatial gait parameters.

FINDINGS

patients with chronic gout had higher levels of general and foot-specific disability, pain and impairment (P ≤0.001). Significantly lower peak plantar pressures were observed in the hallux of patients with chronic gout (P ≤0.05). Significantly higher pressure-time integrals were observed in the cases at the midfoot (P ≤0.05), but lower values were observed at the hallux (P ≤0.05). Patients with chronic gout walked slower, with longer step and stride lengths compared to the controls.

INTERPRETATION

patients with chronic gout experience pain and disability associated with their feet. Different toe-off strategies may account for functional changes and pain associated with foot problems in chronic gout.

Multimorbidity patterns in the elderly: a new approach of disease clustering identifies complex interrelations between chronic conditions

Objective

Multimorbidity is a common problem in the elderly that is significantly associated with higher mortality, increased disability and functional decline. Information about interactions of chronic diseases can help to facilitate diagnosis, amend prevention and enhance the patients' quality of life. The aim of this study was to increase the knowledge of specific processes of multimorbidity in an unselected elderly population by identifying patterns of statistically significantly associated comorbidity.

Methods

Multimorbidity patterns were identified by exploratory tetrachoric factor analysis based on claims data of 63,104 males and 86,176 females in the age group 65+. Analyses were based on 46 diagnosis groups incorporating all ICD-10 diagnoses of chronic diseases with a prevalence ≥ 1%. Both genders were analyzed separately. Persons were assigned to multimorbidity patterns if they had at least three diagnosis groups with a factor loading of 0.25 on the corresponding pattern.

Results

Three multimorbidity patterns were found: 1) cardiovascular/metabolic disorders [prevalence female: 30%; male: 39%], 2) anxiety/depression/somatoform disorders and pain [34%; 22%], and 3) neuropsychiatric disorders [6%; 0.8%]. The sampling adequacy was meritorious (Kaiser-Meyer-Olkin measure: 0.85 and 0.84, respectively) and the factors explained a large part of the variance (cumulative percent: 78% and 75%, respectively). The patterns were largely age-dependent and overlapped in a sizeable part of the population. Altogether 50% of female and 48% of male persons were assigned to at least one of the three multimorbidity patterns.

Conclusion

This study shows that statistically significant co-occurrence of chronic diseases can be subsumed in three prevalent multimorbidity patterns if accounting for the fact that different multimorbidity patterns share some diagnosis groups, influence each other and overlap in a large part of the population. In recognizing the full complexity of multimorbidity we might improve our ability to predict needs and achieve possible benefits for elderly patients who suffer from multimorbidity.

Epidemiology of gout

Gout is the most prevalent form of inflammatory arthropathy. Several studies suggest that its prevalence and incidence have risen in recent decades. Numerous risk factors for the development of gout have been established, including hyperuricaemia, genetic factors, dietary factors, alcohol consumption, metabolic syndrome, hypertension, obesity, diuretic use and chronic renal disease. Osteoarthritis predisposes to local crystal deposition. Gout appears to be an independent risk factor for all-cause mortality and cardiovascular mortality and morbidity, additional to the risk conferred by its association with traditional cardiovascular risk factors.

Role of diet in rheumatic disease

Millions of people suffer from rheumatic diseases such as gout, fibromyalgia, osteoarthritis, and rheumatoid arthritis. These can be incapacitating and detrimental to quality of life. Diet, nutrition, and weight loss have shown promise in alleviating some of this disease burden. These lifestyle changes may give patients a feeling of control and ownership over their disease as well as a nonpharmacologic means of treatment. This article reviews the available research on the effects of diet and nutrition on rheumatoid disease.

Current and future therapeutic options for the management of gout

The incidence of gout and the clinical manifestation of hyperuricemia continue to rise. In addition to painful acute attacks, chronic gout can lead to the development of crystal arthropathy, tophi, and renal lithiasis, coincidental with declines in quality of life. As a greater appreciation for the associations between hyperuricemia, gout, and certain comorbidities, such as renal impairment and cardiovascular diseases, grows, so does the search for new therapeutic options to both alleviate the painful symptoms of acute gout attacks and reduce the underlying hyperuricemia. This manuscript reviews the pathophysiology of hyperuricemia and gout, and associated comorbidities, and then discusses traditional therapeutic options, newly available agents, and future targets for pharmacologic management.

The serum urate-lowering impact of weight loss among men with a high cardiovascular risk profile: the Multiple Risk Factor Intervention Trial

OBJECTIVES

To evaluate the person-level impact of weight loss on serum urate levels among men with a high cardiovascular risk profile.

METHODS

We analysed 12,379 men (mean serum urate level=407 μmol/l) from the Multiple Risk Factor Intervention Trial, using data prospectively collected at baseline and annually over a 7-year period (78,881 visits). Our endpoint was normouricaemia, defined by serum urate levels≤360 μmol/l, a widely accepted therapeutic target. Person-level effects were estimated using conditional logistic regression models to adjust for time-varying covariates (age, congestive heart failure, hypertension, diuretic use, renal function, alcohol intake and dietary factors).

RESULTS

There was a graded relation between weight loss and achieving normouricaemia (P-value for trend<0.001). Compared with no weight change (-0.9 to 0.9 kg), the multivariate odds ratios of achieving normouricaemia for a weight loss of 1-4.9, 5-9.9 and ≥10 kg were 1.43 (95% CI: 1.33, 1.54), 2.17 (1.95, 2.40) and 3.90 (3.31, 4.61), respectively. The corresponding serum urate level changes were -7, -19 and -37 μmol/l (-0.12, -0.31 and -0.62 mg/dl). Similar levels of associations persisted among subgroups stratified by demographics, presence of gout, hypertension, diuretic use, renal insufficiency, alcohol intake, trial group assignment and adiposity categories (all P-values for trend<0.001).

CONCLUSIONS

Weight reduction could help achieve a widely accepted therapeutic urate target level (≤360 μmol/l) among men with a high cardiovascular risk profile. Although the urate-lowering effect appeared weaker than that of urate-lowering drugs, other associated health benefits would make weight reduction important, particularly in this population.

Impact of diabetes against the future risk of developing gout

OBJECTIVE

Although hyperuricaemia and gout are associated with an increased future risk of diabetes, diabetes may reduce the future risk of gout through the uricosuric effect of glycosuria or the impaired inflammatory response. The present work evaluates the impact of diabetes on the future risk of developing gout.

METHODS

A case-control study nested in a UK general practice database (the health improvement network) was conducted by identifying all incident cases of gout (N=24 768) and randomly sampling 50,000 controls who were 20-89 years between 2000 and 2007. The independent effect of type 1 and type 2 diabetes on the development of incident gout was examined.

RESULTS

After adjusting for age, sex, body mass index, general practitioner visits, smoking, alcohol intake, ischaemic heart disease and presence of cardiovascular risk factors, the RR for incident gout among patients with diabetes, as compared with individuals with no diabetes was 0.67 (95% CI 0.63 to 0.71). The multivariate RRs with the duration of diabetes of 0-3, 4-9 and ≥ 10 years were 0.81 (95% CI 0.74 to 0.90), 0.67 (95% CI 0.61 to 0.73) and 0.52 (95% CI 0.46 to 0.58), respectively. The inverse association was stronger with type 1 diabetes than with type 2 diabetes (multivariate RR, 0.33 vs 0.69) and stronger among men than women (p value for interaction < 0.001).

CONCLUSIONS

Individuals with diabetes are at a lower future risk of gout independent of other risk factors. These data provide support for a substantial role of the pathophysiology associated with diabetes against the risk of developing gout.

Management of gout: beyond allopurinol

The basic concepts of the pathogenesis and management of gout have not altered for many years. Monosodium urate monohydrate crystals drive the disease and identification of these crystals is required for certain diagnosis. In contrast, our understanding of the mediators of gouty inflammation, the appropriate target serum urate concentration during treatment, the drugs available and the best ways to use those drugs have all advanced in recent years and will be the focus of this review.

The genetic basis of hyperuricaemia and gout

Gout results from elevated urate concentrations in the blood (hyperuricaemia). When super-saturation of urate is reached, monosodium urate crystals form within the joint. In some individuals, these crystals elicit a painful self-limiting inflammatory response that is characteristic of acute gouty arthritis. The most important cause of hyperuricaemia is reduced excretion of uric acid in the urine. Uric acid excretion is coordinated by a suite of urate transport molecules expressed in the renal collecting tubules, and is a key physiological checkpoint in gout. Other checkpoints in gout are hepatic production of urate, monosodium urate crystal formation, and initiation of the acute inflammatory response. Genome-wide association scans for genes regulating serum urate concentrations have identified two major regulators of hyperuricaemia- the renal urate transporters SLC2A9 and ABCG2. The risk variants at each gene approximately double the risk for gout in people of Caucasian ancestry, with SLC2A9 also resulting in higher risk for gout in people of Polynesian ancestry, a diverse population characterized by a high prevalence of gout. Ongoing genetic association studies are identifying and confirming other genes controlling serum urate concentrations; although genome-wide association studies in gout per se await recruitment of suitable case sample sets.

Genetics of gout

PURPOSE OF REVIEW

This review provides an update on recent findings with regards to the genetics of hyperuricemia and gout, including recent data from genome-wide association studies (GWAS).

RECENT FINDINGS

Five GWAS around the same time reported that genetic variants of SLC2A9/GLUT9 were associated with lower serum uric acid (SUA) levels and the effects were stronger among women (e.g. SUA level difference per copy of a minor allele, -0.46 mg/dl in women vs. -0.22 mg/dl in men). One study involving four cohorts and one meta-analysis of 14 genome-wide scans found that genetic variants of ABCG2 were associated with higher SUA concentrations and these effects were stronger among men (e.g. uric acid level difference per copy of the minor allele, 0.32 mg/dl in men vs. 0.18 mg/dl in women). Limited data indicate that these associations likely translate into those with the risk of gout. Functional determination that GLUT9 and ABCG2 can transport urate at the apical border of proximal tubules implicates them as substantial players in the renal excretion of urate. Furthermore, five novel genetic loci have been reported in the meta-analysis of 14 genome-wide scans.

SUMMARY

Combined with their activities as urate transporters and their strong associations with serum uric acid concentrations, GLUT9 and ABCG2 appeared to be important modulators of uric acid levels and likely of the risk of gout. Together with a growing list of environmental risk factors, these genetic data add considerably to our understanding of the pathogenesis of hyperuricemia and gout.

A prescription for lifestyle change in patients with hyperuricemia and gout

PURPOSE OF REVIEW

This review summarizes the recent data on lifestyle factors that influence serum uric acid levels and the risk of gout and attempts to provide holistic recommendations, considering both their impact on gout as well as on other health implications.

RECENT FINDINGS

Large-scale studies have clarified a number of long-suspected relations between lifestyle factors, hyperuricemia, and gout, including purine-rich foods, dairy foods, various beverages, fructose, and vitamin C supplementation. Furthermore, recent studies have identified the substantial burden of comorbidities among patients with hyperuricemia and gout.

SUMMARY

Lifestyle and dietary recommendations for gout patients should consider overall health benefits and risk, since gout is often associated with the metabolic syndrome and an increased future risk of cardiovascular disease (CVD) and mortality. Weight reduction with daily exercise and limiting intake of red meat and sugary beverages would help reduce uric acid levels, the risk of gout, insulin resistance, and comorbidities. Heavy drinking should be avoided, whereas moderate drinking, sweet fruits, and seafood intake, particularly oily fish, should be tailored to the individual, considering their anticipated health benefits against CVD. Dairy products, vegetables, nuts, legumes, fruits (less sugary ones), and whole grains are healthy choices for the comorbidities of gout and may also help prevent gout by reducing insulin resistance. Coffee and vitamin C supplementation could be considered as preventive measures as these can lower urate levels, as well as the risk of gout and some of its comorbidities.

New insights into the epidemiology of gout

Gout is a true crystal deposition disease caused by formation of monosodium urate crystals in joints and other tissues. It is a common inflammatory arthritis that has increased in prevalence in recent decades. Gout normally results from the interaction of genetic, constitutional and environmental risk factors. It is more common in men and strongly age related. A major determinant is the degree of elevation of uric acid levels above the saturation point for urate crystal formation, principally caused by inefficient renal urate excretion. Local joint tissue factors may influence the topography and extent of crystal deposition. Recent studies have provided information on dietary risk factors for gout: higher intakes of red meat, fructose and beer are independently associated with increased risk, whereas higher intakes of coffee, low-fat dairy products and vitamin C are associated with lower risk. Several renal urate transporters have been identified including URAT1 and SLC2A9 (GLUT9) and polymorphisms in these genes are associated with an increased risk of hyperuricaemia and gout. Many drugs influence serum uric acid levels through an effect on renal urate transport. Comorbidities, including the metabolic syndrome and impaired renal function are common in gout patients. The usual initial presentation of gout is with rapidly developing acute inflammatory monoarthritis, typically affecting the first MTP joint. If left untreated it may progress with recurrent acute attacks and eventual development of chronic symptoms and joint damage. New knowledge of the modifiable risk factors for gout can be integrated into the management strategy to optimize long-term patient outcomes.

Rheumatic manifestations of endocrine diseases

PURPOSE OF REVIEW

Musculoskeletal complaints accompanying or as a result of endocrine disorders are common and have been well described. This review re-examines these associations in light of newer information on biology and genetics.

RECENT FINDINGS

In this article, we describe the recent studies on pathophysiology of the muscular skeletal complaints in endocrine disease. In addition we report on population as well as genetic studies, which address the relationship between endocrine and rheumatologic disease, both of which are autoimmune.

SUMMARY

Very often, the presentation of rheumatic manifestations is the initial presentation of endocrine disease. Being aware of the presentation as well as the unique physiology of these complaints will help alert the clinician to an early diagnosis of endocrine disease. In addition understanding whether certain endocrine disease occurs more often in rheumatologic illness will enable the clinician to investigate their occurrence early, leading to earlier intervention and resulting in decreased morbidity from these concomitant illnesses.

Gout

Gout is a common arthritis caused by deposition of monosodium urate crystals within joints after chronic hyperuricaemia. It affects 1-2% of adults in developed countries, where it is the most common inflammatory arthritis in men. Epidemiological data are consistent with a rise in prevalence of gout. Diet and genetic polymorphisms of renal transporters of urate seem to be the main causal factors of primary gout. Gout and hyperuricaemia are associated with hypertension, diabetes mellitus, metabolic syndrome, and renal and cardiovascular diseases. Non-steroidal anti-inflammatory drugs and colchicine remain the most widely recommended drugs to treat acute attacks. Oral corticosteroids could be an alternative to these drugs. Interleukin 1beta is a pivotal mediator of acute gout and could become a therapeutic target. When serum uric acid concentrations are lowered below monosodium urate saturation point, the crystals dissolve and gout can be cured. Patient education, appropriate lifestyle advice, and treatment of comorbidities are an important part of management of patients with gout.

Prescription and comorbidity screening following consultation for acute gout in primary care

OBJECTIVE

To describe prescribing patterns and cardiovascular risk factor screening in patients, following consultation for acute gout in primary care.

METHODS

This study was undertaken in two inter-linked regional primary care databases: Consultations in Primary Care Archive (CiPCA) and Prescriptions in Primary Care Archive (PiPCA). During 2001-04, consultations in CiPCA were identified at 10 participating practices from gout-related Read morbidity codes. Lipid, blood pressure, glucose and renal function monitoring were identified from Read codes and consultation free text over the next month. Prescriptions for traditional NSAIDs, gastroprotective agents, colchicine, coxibs, corticosteroids, analgesic agents and urate-lowering therapies (ULTs) issued to these patients over the subsequent 12 months were identified from PiPCA.

RESULTS

Six hundred and seventy-three new gout consultations were identified. Monitoring of lipids (5%), blood pressure (26%), glucose (6%) and renal function (21%) within 1 month of index consultation were infrequently recorded. There were 583 consultations for acute gout. Traditional NSAIDs (68%) were most commonly prescribed, followed by colchicine (15%), coxibs (5%) and analgesia only (5%). Seven per cent did not receive a prescription. The most frequently prescribed traditional NSAIDs were diclofenac (41%) and indomethacin (32%). Gastroprotection was co-prescribed with NSAIDs for 17% of patients. Sixty six per cent of patients treated with colchicine were prescribed high-dose regimens (500 microg at least four times daily). ULTs were prescribed within 12 months in 23% of patients. Nineteen per cent of ULTs were prescribed during acute attack.

CONCLUSIONS

Primary care acute gout management is suboptimal. Education of general practitioners about acute gout management and cardiovascular risk is a priority.

The modern management of gout

Gout is an inflammatory arthritis characterized by self-limiting but excruciatingly painful acute attacks. These are a consequence of monosodium urate (MSU) crystals being deposited within articular or periarticular tissue. Chronic tophaceous gout can develop after years of acute intermittent gout. Recent discoveries, including the role of the inflammasome and intracellular events demonstrating that pro-inflammatory cytokines, IL-1 beta, -8 and TNF-alpha, promote neutrophil influx. Also, genetic advances with the identification of the URAT-1 transporter and genetic variation in SLC 2A9 as a key regulator of urate homoeostasis, have given us deeper understanding of the pathophysiology of gout, and also allow for more targeted treatments. Hopefully, new and emerging therapeutic options will reduce treatment-resistant gout in patients who are unresponsive or unable to take traditional urate lowering therapy. The development of new therapies may also increase patient numbers being treated in the specialist setting, which may have several secondary benefits.

Hypothesis: could excessive fructose intake and uric acid cause type 2 diabetes?

We propose that excessive fructose intake (>50 g/d) may be one of the underlying etiologies of metabolic syndrome and type 2 diabetes. The primary sources of fructose are sugar (sucrose) and high fructose corn syrup. First, fructose intake correlates closely with the rate of diabetes worldwide. Second, unlike other sugars, the ingestion of excessive fructose induces features of metabolic syndrome in both laboratory animals and humans. Third, fructose appears to mediate the metabolic syndrome in part by raising uric acid, and there are now extensive experimental and clinical data supporting uric acid in the pathogenesis of metabolic syndrome. Fourth, environmental and genetic considerations provide a potential explanation of why certain groups might be more susceptible to developing diabetes. Finally, we discuss the counterarguments associated with the hypothesis and a potential explanation for these findings. If diabetes might result from excessive intake of fructose, then simple public health measures could have a major impact on improving the overall health of our populace.