Amputation of the first metatarsophalangeal joint due to a giant gouty tophi: A case report

Comparison of Rates of Lower Extremity Amputation in Patients With and Without Gout in the US Department of Veterans Affairs Health System

Importance

Cardiometabolic and other risk factors could render patients with gout more likely to undergo lower extremity amputation (LEA).

Objective

To examine the rate of and factors associated with LEA in patients with gout.

Design, Setting, and Participants

In this matched cohort study using national administrative data, multivariable Cox proportional hazards regression models were used to examine the associations of gout with LEA. In analyses limited to patients with gout, attributes of serum urate control and treatment with urate-lowering therapy were examined as factors associated with LEA. This study included patients who used US Department of Veterans Affairs services from January 1, 2000, to July 31, 2015. Patients with gout were identified using diagnostic codes and matched with up to 10 controls by age, sex, and year of benefit enrollment. Data analysis was performed from January 26, 2021, to September 3, 2021.

Exposures

Gout classification served as the primary independent variable of interest. In analyses limited to patients with gout, factors associated with serum urate control and urate-lowering therapy were examined.

Main Outcomes and Measures

Overall LEA, as well as toe, transmetatarsal, below-the-knee, and above-the-knee amputation.

Results

This cohort study included 5 924 918 patients, 556 521 with gout (mean [SD] age, 67 [12] years; 550 963 (99.0%) male; 88 853 [16.0%] Black non-Hispanic; 16 981 [4.3%] Hispanic/Latinx; 345 818 [62.1%] White non-Hispanic; 80 929 [14.5%] with race and ethnicity data missing; and 23 940 [4.3%] classified as other) and 5 368 397 without gout (mean [SD] age, 67 [12] years; 5 314 344 [99.0%] male; 558 464 [10.4%] Black non-Hispanic; 204 291 [3.0%] Hispanic/Latinx; 3 188 504 [59.4%] White non-Hispanic; 1 257 739 [23.4%)] with race and ethnicity data missing; and 159 399 [3.0%] classified as other). Compared with patients without gout, patients with gout were more likely to undergo amputation, an increased rate that remained after adjustment (adjusted hazard ratio, 1.20; 95% CI, 1.16-1.24) and was highest for below-the-knee amputation (adjusted hazard ratio, 1.59; 95% CI, 1.39-1.81). In those with gout, poor serum urate control (mean >7 mg/dL during the preceding year) was associated with a 25% to 37% increase in the rate of amputation. In contrast, treatment with urate-lowering therapy was not associated with the LEA rate.

Conclusions and Relevance

In this matched cohort study, patients with gout were more likely to undergo LEA. This increase was independent of other comorbidities that have been associated with amputation, including diabetes and peripheral vascular disease. Serum urate control was independently associated with the LEA rate, suggesting the possibility that lower extremity amputation may be preventable in some patients.

Beyond Medical Treatment: Surgical Treatment of Gout

PURPOSE OF REVIEW

Medical treatment with urate-lowering therapy (ULT) is efficacious. A recent publication suggested that surgery in gout is more prevalent than previously reported. This revelation led us to review what is known about surgical treatment of gout.

RECENT FINDINGS

The Google Scholar database (January 1, 2014-January 1, 2020) found 104 publications with a total of 169 gout patients, with an average disease duration of 6.7 years. Most (68%) were not on ULT. The mean pre-operative serum urate levels were 9.19 mg/dL. One hundred thirteen patients underwent tophi excision, while in 33 patients, tophi were found during surgery. The majority of the surgeries were performed in Asia and Europe. Most patients were not taking ULT at the time of surgery, leading to hyperuricemia. This can result in tophi reformation post-surgery. The role of surgery should be a last-line treatment and until recently has only been demonstrated through case reports.

Effects of febuxostat on serum cytokines IL-1, IL-4, IL-6, IL-8, TNF-α and COX-2

Effects of febuxostat on serum cytokines interleukin (IL)-1, IL-4, IL-6, IL-8, tumor necrosis factor-α (TNF-α) and cyclooxygenase-2 (COX-2) in patients with gout were investigated. A total of 80 patients with gout admitted and treated in the Affiliated Zhongshan Hospital of Dalian University from January 2015 to September 2017 were selected and divided into two groups by virtue of a random number table, with 40 patients in each group. All the enrolled patients received strict gout diet adjustment and took colchicine at the same time. Patients in the control group were additionally treated with allopurinol, while those in the the observation group were administered with febuxostat. The serum uric acid levels were compared between the two groups. The number of gout attacks and adverse reactions were recorded, and the variations in COX-2 positive value integral were clarified. At different time-points of observation, the serum uric acid levels in the observation group were significantly lower than those in the control group (p<0.05). Moreover, at 3 months after treatment, the levels of inflammatory cytokines in the serum in the observation group were decreased compared with those in the control group (p<0.05). The IL-1 and TNF-α levels were lower in the observation group at 1 week, 1 and 3 months after treatment compared with those in the control group (p<0.05). Furthermore, it was discovered that at 3 months after treatment, the COX-2 positive value integral in the observation group was superior to that in the control group (p<0.05). During follow-up, the number of gout attacks that needed medical intervention in the observation group was smaller than that in the control group (p<0.05). Compared with allopurinol therapy, febuxostat therapy can remarkably inhibit inflammatory responses in the body, relieve clinical symptoms and reduce relapse of the patients with gout.