Comorbidity in gout at the time of first diagnosis: sex differences that may have implications for dosing of urate lowering therapy

Gender differences in the relationship between serum uric acid and the long-term prognosis in heart failure: a nationwide study

BACKGROUND

Serum uric acid (SUA) is an important pathogenetic and prognostic factor for heart failure (HF). Gender differences are apparent in HF. Furthermore, gender differences also exist in the association between SUA and prognosis in various cardiovascular diseases. However, the gender difference for SUA in the prediction of long-term prognosis in HF is still ambiguous.

METHODS

A total of 1593 HF patients (897 men, 696 women) from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 cycle were enrolled in our final analysis. Participants were categorized according to gender-specific SUA tertile. We assessed the association between SUA and long-term prognosis of HF patients, defined as all-cause mortality and cardiovascular mortality, in different genders via Kaplan-Meier curve analysis, Cox proportional hazard model, and Fine-Gray competing risk model. The restricted cubic spline (RCS) was performed to investigate the dose-response relationship between SUA and outcomes.

RESULTS

Gender differences exist in demographic characteristics, clinical parameters, laboratory tests, and medication of HF patients. After a median follow-up of 127 months (95% CI 120-134 months), there were 853 all-cause deaths (493 events in men, 360 events in women) and 361 cardiovascular deaths (206 events in men, 155 events in women). Kaplan-Meier analysis showed that SUA had gender difference in the prediction of cardiovascular mortality (Log-rank p < 0.001, for male, Log-rank p = 0.150, for female), but not in all-cause mortality. Multivariate Cox regression analysis revealed that elevated SUA levels were associated with higher all-cause mortality and cardiovascular mortality in men (HR 1.11, 95% CI 1.05-1.18, p < 0.001, for all-cause death; HR 1.18, 95% CI 1.09-1.28, p < 0.001, for cardiovascular death), but not in women (HR 1.05, 95% CI 0.98-1.12, p = 0.186, for all-cause death; HR 1.01, 95% CI 0.91-1.12, p = 0.902, for cardiovascular death). Even using non-cardiovascular death as a competitive risk, adjusted Fine-Gray model also illustrated that SUA was an independent predictor of cardiovascular death in men (SHR 1.17, 95% CI 1.08-1.27, p < 0.001), but not in women (SHR 0.98, 95% CI 0.87 - 1.10, p = 0.690).

CONCLUSIONS

Gender differences in the association between SUA and long-term prognosis of HF existed. SUA was an independent prognostic predictor for long-term outcomes of HF in men, but not in women.

Sex and country differences in gout: cross-country comparison between Sweden and the UK

OBJECTIVE

Compare characteristics, sex differences, and management of gout in Sweden and the UK.

METHOD

The results from two separate primary care gout surveys from Sweden and the UK were compared. Participants aged ≥18 years with gout were sent a questionnaire asking about lifestyle, gout characteristics, uratelowering therapy (ULT), comorbidities, disability, and disease impact. For sex comparison, participants were pooled across countries.

RESULTS

In total, 784 (80% male) participants from Sweden and 500 (87% male) from the UK were included. Swedish patients were significantly older at gout onset, mean (SD) age 72 (12) versus 63 (13) years, (p<0.0001), with more comorbidities, and more frequent use of ULT (48% vs 35%, p=0.0005, age-adjusted). Use of alcohol and diuretics was significantly more common among UK patients, who also reported a higher number of gout flares, mean (SD) 2.2 (1.7) versus 1.6 (3.6), (p=0.003) age-adjusted. Females with gout were older at gout onset, mean (SD) age 67 (13) versus 56 (15), (p<0.0001), more often obese, and reported higher use of diuretics. Furthermore, females reported greater impact of gout, more pain and physical limitations, whereas no sex differences were seen in ULT or flares.

CONCLUSIONS

In the UK, gout was more frequently associated with modifiable risk factors. People with gout in Sweden were more commonly taking ULT and had lower frequency of gout flares and impact of gout. Females with gout more commonly took diuretics, had higher body mass index, and reported greater physical disability, which should be considered when managing gout in women.

Health-related quality of life in gout, psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis, results from a cross-sectional survey in Western Sweden

OBJECTIVES

Inflammatory joint diseases (IJDs) substantially affect health-related quality of life (HRQoL). We aimed to compare HRQoL between patients with gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA), and ankylosing spondylitis (AS): (i) overall; (ii) stratified by sex; and (iii) between women and men with the same IJD diagnosis.

METHOD

A survey including the RAND36-Item Health Survey for assessing HRQoL was sent to patients with a diagnosis of gout, PsA, RA, or AS, registered at a rheumatology clinic or primary care centre during 2015-2017. HRQoL was compared across IJDs. Because of age differences between diagnoses, age-matched analyses were performed.

RESULTS

In total, 2896/5130 (56.5%) individuals responded to the questionnaire. Of these, 868 had gout, 699 PsA, 742 RA, and 587 AS. Physical component summary (PCS) scores were more affected than mental component summary (MCS) scores for all diagnoses (PCS range: 39.7-41.2; MCS range: 43.7-48.9). Patients with gout reported better PCS scores than patients with PsA, RA, and AS, who reported similar scores in age-matched analysis. MCS scores were close to normative values for the general population and similar across IJDs. When comparing women and men with respective IJDs, women reported worse PCS (range, all IJDs: 34.5-37.4 vs 37.5-42.5) and MCS (PsA: 44.0 vs 46.8; RA: 46.1 vs 48.7) scores.

CONCLUSION

We found that patients with gout reported better PCS scores than patients with other IJDs, for whom the results were similar. Women reported overall worse PCS and MCS scores than men.

Exploring the inhibition mechanism of interleukin-1-beta in gouty arthritis by polygonum cuspidatum using network pharmacology and molecular docking: A review

Polygonum cuspidatum (Huzhang, HZ) is one of the commonly used traditional Chinese medicines for treating gouty arthritis (GA), but the specific mechanism is not clear. This study employed network pharmacology and molecular docking techniques to examine the molecular mechanisms underlying the therapeutic effects of HZ on GA. The network pharmacology approach, including active ingredient and target screening, drug-compound-target-disease network construction, protein-protein interaction (PPI) networks, enrichment analysis, and molecular docking, was used to explore the mechanism of HZ against GA. Ten active ingredients of HZ were predicted to interact with 191 targets, 14 of which interact with GA targets. Network pharmacology showed that quercetin, physovenine, luteolin, and beta-sitosterol are the core components of HZ, and IL (interleukin)-1β, IL-6, and tumor necrosis factor (TNF) are the core therapeutic targets. The mechanism of HZ in GA treatment was shown to be related to the IL-17 signaling pathway, NOD-like receptor signaling pathway, and Toll-like receptor signaling pathway, and is involved in the inflammatory response, positive regulation of gene expression, cellular response to lipopolysaccharide, and other biological processes. Molecular docking showed that all four core compounds had good binding properties to IL-1β, with luteolin and beta-sitosterol showing better docking results than anakinra, suggesting that they could be used as natural IL-1β inhibitors in further experimental studies. The mechanism of action of HZ against GA has multi-target and multi-pathway characteristics, which provides an important theoretical basis for the study of the active ingredients of HZ as natural IL-1β inhibitors.

Uric acid en route to gout

Gout and hyperuricemia (HU) have generated immense attention due to increased prevalence. Gout is a multifactorial metabolic and inflammatory disease that occurs when increased uric acid (UA) induce HU resulting in monosodium urate (MSU) crystal deposition in joints. However, gout pathogenesis does not always involve these events and HU does not always cause a gout flare. Treatment with UA-lowering therapeutics may not prevent or reduce the incidence of gout flare or gout-associated comorbidities. UA exhibits both pro- and anti-inflammation functions in gout pathogenesis. HU and gout share mechanistic and metabolic connections at a systematic level, as shown by studies on associated comorbidities. Recent studies on the interplay between UA, HU, MSU and gout as well as the development of HU and gout in association with metabolic syndromes, non-alcoholic fatty liver disease (NAFLD), and cardiovascular, renal and cerebrovascular diseases are discussed. This review examines current and potential therapeutic regimens and illuminates the journey from disrupted UA to gout.

Gender differences in illness perceptions and disease management in patients with gout, results from a questionnaire study in Western Sweden

BACKGROUND

Aims were to examine gender differences in patients with gout with regard to a) self-reported gout severity, b) illness perceptions (IP), c) impact on daily activities and Quality of Life (QoL), d) advice from healthcare professionals, e) having changed dietary- or alcohol habits.

METHODS

Adult patients with gout identified in primary and secondary care in Sweden between 2015 and 2017 (n = 1589) were sent a questionnaire about demographics, gout disease severity, IP (using the Brief Illness Perception Questionnaire, (B-IPQ)) and disease management. T-tests, Chi square tests, ANalysis Of VAriance (ANOVA) and linear regression models were used for gender comparisons.

RESULTS

Eight hundred sixty-eight patients responded to the questionnaire. Women, n = 177 (20%), experienced more severe gout symptoms (p = 0.011), albeit similar frequencies of flares compared to men. Women experienced modest but significantly worse IP with regard to consequences, identity, concerns and emotional response (p < 0.05) as well as daily activities such as sleeping (p < 0.001) and walking (p = 0.042) and QoL (p = 0.004). Despite this and a higher frequency of obesity in women (38 vs 21%, P < 0.001) and alcohol consumption in men (p < 0.001), obese women had received significantly less advice regarding weight reduction (47 vs 65%, p = 0.041) compared to obese men. On the other hand, women reported having acted on dietary advice to a larger degree.

CONCLUSIONS

Despite only modestly worse gout severity and perception, women appear to have been given less information regarding self-management than men. These gender differences should be given attention and addressed in clinical care.

Gout and risk of venous thromboembolism: A systematic review and meta-analysis of cohort studies

BACKGROUND

The association between gout and venous thromboembolism (VTE) remains ambiguous, and the results of current studies are inconsistent. A systematic review and meta-analysis of cohort studies were conducted to comprehensively assess the associations between gout and VTE and its subtypes, deep venous thrombosis (DVT) and pulmonary embolism (PE).

METHODS

PubMed, Web of Science, Embase, Scopus, and the Cochrane Library databases were searched up to June 2021, to identify eligible cohort studies, reporting the association of gout with VTE and its subtypes. We pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Subgroup analysis, sensitivity analysis, and publication bias tests were also conducted.

RESULTS

Five studies involving 642 632 individuals were included. Patients with gout had a statistically significantly higher risk of VTE (HR: 1.33; 95% CI: 1.21, 1.46; P < .001) compared with non-gout controls, and significant associations were also found between gout and DVT (HR: 1.40; 95% CI: 1.22, 1.62; P < .001) and PE (HR: 1.18; 95% CI: 1.07, 1.30; P = .001). Subgroup analysis showed this association in men (HR: 1.37; 95% CI: 1.14, 1.65; P = .001) and women (HR: 1.36; 95% CI: 1.21, 1.53; P < .001) were consistent (P = .980). Meta-regression analysis revealed publication year (P = .005) and quality of study (P = .006) contributed to heterogeneity.

CONCLUSIONS

In conclusion, our study provided evidence that gout was associated with the risk of VTE and its subtypes DVT and PE. However, more prospective and high-quality clinical evidence is required to confirm our findings.

High Prevalence of Hyperuricemia and Associated Factors among Zhuang Adults: A Cross-Sectional Study Based on the Ethnic Minority Population Cohort in the Southwestern China

The highest prevalence of hyperuricemia was found in Zhuang minority adults in two national surveys in China, with only 1% Zhuang study subjects. However, the prevalence of hyperuricemia and the associated factors in Zhuang adults have not been well-addressed. A cross-sectional study was conducted to explore the prevalence of hyperuricemia and the common comorbidities, and the associated factors in Zhuang adults based on the Guangxi Ethnic Minority Population Cohort. Among 11,175 Zhuang adults aged 35-74 years, the age- and sex-standardized prevalence rate was 18.1% for hyperuricemia and 1.1% for gout. The standardized prevalence rate and awareness rate were 31.6% and 32.3%, respectively, for hypertension, and were 5.1% and 48.2%, respectively, for diabetes. High education level, history of coronary heart disease (CHD), hypertension, being a current drinker, high body mass index (BMI), central obesity, hyper-triglyceride (hyper-TG), hyper-total cholesterol (hyper-TC), hypo-high density lipoprotein cholesterol (hypo-HDL-C), and abnormal aspartate aminotransferase (AST) were risk factors, while smoking and diabetes were protective factors of hyperuricemia in males. Older age, being single/divorced, having a high education level, hypertension, drinking tea, high BMI, central obesity, hyper-TG, hyper-TC, hypo-HDL-C, and abnormal alanine aminotransferase (ALT) were risk factors in females. The high prevalence of hyperuricemia but low prevalence of gout and common comorbidities in Zhuang adults may be due to a lag effect of lifestyle changes. Health education and health management should be strengthened to prevent the progression of comorbidities, considering the lag effect and low awareness rate.

Incident Gout and Risk of First-Time Acute Coronary Syndrome: A Prospective, Population-Based Cohort Study in Sweden

OBJECTIVE

To investigate the risk of first-time acute coronary syndrome (ACS) in a large cohort of primary and secondary care patients with incident gout compared to the general population.

METHODS

Using register data for the period 2007-2017, we conducted a prospective, population-based cohort with 20,146 patients with incident gout (mean age 65.6 years; 67.4% male) and 83,517 matched population controls without prior history of coronary heart disease. We calculated incidence rates (IRs) and hazard ratios (HRs) adjusted for baseline comorbidities and dispensed prescriptions. In a sensitivity analysis, we included gout cases and controls with no previously diagnosed comorbidity (6,075 cases and 44,091 controls).

RESULTS

The IR of first-time ACS was significantly increased in the gout cohort compared to controls (9.1 versus 6.3 of 1,000 person-years). Unadjusted Cox regression showed that gout patients had higher risk of first-time ACS compared to controls (HR 1.44 [95% confidence interval (95% CI) 1.33-1.56]), with a higher HR in women (HR 1.64 [95% CI 1.41-1.90]) than in men (HR 1.36 [95% CI, 1.24-1.50]). In multivariable analysis, the risk diminished but remained significant (HR 1.15 [95% CI 1.06-1.25]). The risk was similar in the sensitivity analysis (HR 1.20 [95% CI 1.01-1.44]) and still higher in women (HR 1.34 [95% CI 0.86-2.08]) than in men (HR 1.18 [95% CI 0.97-1.44]).

CONCLUSION

Patients with incident gout have a 44% increased risk of first-time ACS, higher in women than in men. This risk is largely explained by the underlying comorbidities, but there is still a modestly increased risk that may be due to gout-related factors.

A glance into the future of gout

Gout is characterized by monosodium urate (MSU) crystal deposits in and within joints. These deposits result from persistent hyperuricaemia and most typically lead to recurrent acute inflammatory episodes (gout flares). Even though some aspects of gout are well characterized, uncertainties remain; this upcoming decade should provide further insights into many of these uncertainties. Synovial fluid analysis allows for the identification of MSU crystals and unequivocal diagnosis. Non-invasive methods for diagnosis are being explored, such as Raman spectroscopy and imaging modalities. Both ultrasound and dual-energy computed tomography (DECT) allow the detection of MSU crystals; this not only provides a mean of diagnosis, but also has furthered gout knowledge defining the presence of a preclinical deposition in asymptomatic hyperuricaemia. Scientific consensus establishes the beginning of gout as the beginning of symptoms (usually the first flare), but the concept is currently under review. For effective long-term gout management, the main goal is to promote crystal dissolution treatment by reducing serum urate below 6 mg/dL (or 5 mg/dL if faster crystal dissolution is required). Current urate-lowering therapies' (ULTs) options are limited, with allopurinol and febuxostat being widely available, and probenecid, benzbromarone, and pegloticase available in some regions. New xanthine oxidase inhibitors and, especially, uricosurics inhibiting urate transporter URAT1 are under development; it is probable that the new decade will see a welcomed increase in the gout therapeutic armamentarium. Cardiovascular and renal comorbidities are common in gout patients. Studies determining whether optimal treatment of gout will positively impact these comorbidities are currently lacking, but will hopefully be forthcoming. Overall, the single change that will most impact gout management is greater uptake of international rheumatology society recommendations. Innovative strategies, such as nurse-led interventions based on these recommendations have recently demonstrated treatment success for people with gout.

Gout and Hospital Admission for Ambulatory Care-Sensitive Conditions: Risks and Trajectories

OBJECTIVE

To investigate the risks and trajectories of hospital admission for ambulatory care-sensitive conditions (ACSCs) in gout.

METHODS

Among individuals aged 35 years to 85 years residing in Skåne, Sweden, in 2005, those with no doctor-diagnosed gout during 1998 to 2005 (n = 576,659) were followed from January 1, 2006, until a hospital admission for an ACSC, death, relocation outside Skåne, or December 31, 2016. Treating a new gout diagnosis (International Classification of Diseases, 10th revision, code M10) as a time-varying exposure, we used Cox proportional and additive hazard models to estimate the effects of gout on hospital admissions for ACSCs. We investigated the trajectory of hospital admissions for ACSCs from 3 years before to 3 years after gout diagnosis using generalized estimating equations and group-based trajectory modeling in an age-and sex-matched cohort study.

RESULTS

Gout was associated with a 41% increased rate of hospital admission for ACSCs (hazard ratio 1.41, 95% CI 1.35-1.47), corresponding to 121 (95% CI 104-138) more hospital admissions for ACSCs per 10,000 person-years compared with those without gout. Our trajectory analysis showed that higher rates of hospital admission for ACSCs among persons with gout were observed from 3 years before to 3 years after diagnosis, with the highest prevalence rate ratio (2.22, 95% CI 1.92-2.53) at the 3-month period after diagnosis. We identified 3 classes with distinct trajectories of hospital admissions for ACSCs among patients with gout: almost none (88.5%), low-rising (9.7%), and moderate-sharply rising (1.8%). The Charlson Comorbidity Index was the most important predictor of trajectory class membership.

CONCLUSION

Increased risk of hospital admissions for ACSCs in gout highlights the need for better management of the disease through outpatient care, especially among foreign-born, older patients with comorbidities.

Professionals' perspectives on existing practice and conditions for nurse-led gout care based on treatment recommendations: a qualitative study in primary healthcare

BACKGROUND

Gout affects nearly 2 % of the population and is associated with repeated painful flares of arthritis. Preventive urate-lowering therapy is widely available, but only one third of patients receive adequate treatment. Lack of knowledge among healthcare professionals and patients within primary healthcare are implicated as partial explanations for this undertreatment. Nurse-led care has proved to be an effective model when treating patients with gout, but there is a need for more knowledge about factors that can be expected to influence the future implementation of such care. The aim of this study was to describe factors influencing existing gout care in primary healthcare and the conditions for a future implementation of nurse-led gout care based on national treatment recommendations.

METHODS

In this qualitative study, focus group discussions with 56 nurses and physicians and individual interviews with eight managers were conducted at nine primary healthcare units in central Sweden. A deductive qualitative content analysis based on the main constructs of the framework Integrated Promoting Action on Research Implementation in Health Services was followed by an inductive analysis within the frames of the main constructs: innovation, recipients and context.

RESULTS

Gout-related contacts with primary healthcare was described as being patient initiated, diagnostics was in some respects complex and nurse-led care was experienced as a favourable primary healthcare model in general (innovation). Gout was seen as a low-priority condition with acute flares and there was inadequate knowledge of gout, including preventive treatment (recipients). Primary healthcare was perceived as having a holistic but fragmented responsibility for gout care, recommendations against keeping waiting lists complicated follow-up appointments and a need for motivation and support when introducing new practices was emphasised (context).

CONCLUSION

In this study, investigating the perspective of professionals, several factors were found to influence existing gout care. It will be crucial to target these factors in the development of a future implementation strategy.

Incident Gout: Risk of Death and Cause-Specific Mortality in Western Sweden: A Prospective, Controlled Inception Cohort Study

Background

Excess mortality in gout has been attributed to cardiovascular diseases (CVD). Considering the decline in CVD mortality in the general population, we wanted to evaluate overall mortality in gout and cause-specific contributions to mortality beyond CVD and temporal trends.

Methods

All incident cases of gout between 2006 and 2015 in western Sweden and 5 population controls per case matched for age, sex, and county were identified. Comorbidities were identified for 5 years preceding the index date. Follow-up ended at death, migration, or end of study on December 2017. Effect of gout on death risk was calculated using COX regression on the whole population and stratified by sex, adjusted for demographics, and comorbidities. Death incidence rates were compared between the two time periods, 2006-2010 and 2011-2015.

Results

We identified 22,055 cases of incident gout and 98,946 controls, median age (Q1, Q3) 69-68 (57, 79/56, 78) years and 67.6-66.5% males. Except for dementia, all comorbidities were significantly more common at baseline among gout cases. Overall, the risk for death in incident gout was neither increased overall nor in men, but women had a 10% elevated risk. In adjusted models for cause-specific mortality, death from CVD, renal disease, and digestive system diseases were significantly increased in the total gout population while death from dementia, cancer, and lung diseases were significantly decreased. There were no significant differences in overall incident death rate ratios between cases and controls in the two time periods examined.

Conclusions

An increased risk for CVD, renal disease, and diseases of the digestive system in patients with gout highlights the importance of addressing CVD risk factors in gout management. Gout was associated with reduced mortality from dementia, which may have implications on urate lowering therapy and possible effects on dementia risk.

Lifestyle factors and comorbidities in gout patients compared to the general population in Western Sweden: results from a questionnaire study

OBJECTIVE

This study aimed to identify lifestyle factors associated with gout in patients with prevalent gout compared to the general population.

METHOD

Adult patients with gout identified in primary and secondary care in Western Sweden between 2015 and 2017 were sent a questionnaire asking about demographics, lifestyle, and comorbidities. Five age- and gender-matched controls were identified in a random sample of 52 348 individuals aged 16-84 years who participated in the National Public Health survey in Sweden, year 2015. Logistic regression models were used to compare cases and controls with regard to lifestyle factors and comorbidities.

RESULTS

Of the 1589 invited gout patients, 868 (55%) responded. After matching for age and gender, 728 were included in the analysis (82.4% male; mean ± sd age 69.3 ± 10.5 years for men and 71.8 ± 9.9 years for women with gout). Male and female gout patients were significantly more likely to be overweight or obese (men 79% vs 66%; women 78.5% vs 65.3%), to have binge-drinking behaviour (men 29.9% vs 11%; women 13.7% vs 2.9%), and to be ex-smokers, compared to controls. Moreover, male gout patients reported lower levels of physical activity, while diabetes and hypertension were more common in both genders with gout than in controls.

CONCLUSION

In this questionnaire study, gout patients reported significantly more obesity and binge-drinking behaviour and less physical activity than controls. This suggests that there are great unmet needs for the management of lifestyle factors, particularly regarding overweight/obesity and binge drinking, in patients with gout.

Adherence to 2020 to 2025 Dietary Guidelines for Americans and the Risk of New-Onset Female Gout

IMPORTANCE

Female-specific gout data are scarce despite perceived differences from males in its risk factors and disproportionate worsening in disease and comorbidity burden globally. The 2020 to 2025 Dietary Guidelines for Americans recommend multiple healthy eating patterns for prevention of cardiovascular-metabolic outcomes, which may also be relevant to the prevention of female gout.

OBJECTIVE

To examine the associations of dietary scores for the latest guideline-based healthy eating patterns with risk of incident female gout.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 80 039 US women in the Nurses' Health Study followed up through questionnaires every 2 years starting from 1984. Participants had no history of gout at baseline, and the study used questionnaire responses through 2018. Statistical analyses were performed over September 2020 to August 2021.

EXPOSURES

Four healthy eating patterns: Dietary Approaches to Stop Hypertension (DASH), Alternate Mediterranean Diet Score, Alternative Healthy Eating Index (AHEI), and Prudent, plus Western (unhealthy) for comparison, with scores derived from validated food frequency questionnaires.

MAIN OUTCOMES AND MEASURES

Incident, physician-diagnosed female-specific gout.

RESULTS

During 34 years of follow-up, we documented 3890 cases of incident female gout. Compared with the least-adherent quintile, women most adherent to healthy diets had significantly lower risk of incident gout, with multivariable-adjusted hazard ratios (HRs) 0.68 (95% CI, 0.61-0.76) (DASH), 0.88 (95% CI, 0.80-0.98) (Mediterranean), 0.79 (95% CI, 0.71-0.89) (AHEI), and 0.75 (95% CI, 0.73-0.90) (Prudent); all P for trend ≤.009. Conversely, women with highest-quintile Western diet score had 49% higher risk of gout (HR, 1.49; 95% CI, 1.33-1.68], P <.001). When combined, the most DASH-diet adherent women with normal body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) had a 68% lower risk of gout compared with the least adherent women with overweight or obese BMI; the corresponding risk reduction was 65% combining high DASH diet adherence with no diuretic use.

CONCLUSIONS AND RELEVANCE

These large-scale, long-term prospective cohort findings extend the pleotropic benefits of the 2020 to 2025 Dietary Guidelines for Americans to female gout prevention, with multiple healthy diets that can be adapted to individual food traditions, preferences, and comorbidities.

Impact of adiposity on risk of female gout among those genetically predisposed: sex-specific prospective cohort study findings over >32 years

OBJECTIVES

To evaluate the joint (combined) association of excess adiposity and genetic predisposition with the risk of incident female gout, and compare to their male counterparts; and determine the proportion attributable to body mass index (BMI) only, genetic risk score (GRS) only, and to their interaction.

METHODS

We prospectively investigated potential gene-BMI interactions in 18 244 women from the Nurses' Health Study and compared with 10 888 men from the Health Professionals Follow-Up Study. GRS for hyperuricaemia was derived from 114 common urate-associated single nucleotide polymorphisms.

RESULTS

Multivariable relative risk (RR) for female gout was 1.49 (95% CI 1.42 to 1.56) per 5 kg/m² increment of BMI and 1.43 (1.35 to 1.52) per SD increment in the GRS. For their joint association of BMI and GRS, RR was 2.18 (2.03 to 2.36), more than the sum of each individual factor, indicating significant interaction on an additive scale (p for interaction <0.001). The attributable proportions of joint effect for female gout were 42% (37% to 46%) to adiposity, 37% (32% to 42%) to genetic predisposition and 22% (16% to 28%) to their interaction. Additive interaction among men was smaller although still significant (p interaction 0.002, p for heterogeneity 0.04 between women and men), and attributable proportion of joint effect was 14% (6% to 22%).

CONCLUSIONS

While excess adiposity and genetic predisposition both are strongly associated with a higher risk of gout, the excess risk of both combined was higher than the sum of each, particularly among women.

Cardiovascular risk factors in gout, psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis: a cross-sectional survey of patients in Western Sweden

Objectives

We aimed to compare traditional (trad) cardiovascular risk factors (CVRFs) among patients with gout, psoriatic arthritis (PsA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) stratified by sex.

Methods

A survey was sent to patients with gout (n=1589), PsA (n=1200), RA (n=1246) and AS (n=1095). Patients were retrieved from Sahlgrenska University Hospital, the hospitals of Uddevalla and Skövde, and 12 primary care centres in Western Sweden. The prevalence of self-reported trad-CVRFs was compared between diagnoses by age standardisation with the 2018 population of Sweden as the standard population.

Results

In total, 2896 (56.5%) of 5130 patients responded. Hypertension was the most frequently found comorbidity, reported by 65% of patients with gout, 41% with PsA, 43% with RA and 29% with AS. After age standardisation, women and men with gout had significantly more obesity (body mass index ≥30 kg/m²), hypertension, diabetes, hyperlipidaemia and multiple trad-CVRFs, compared with those with PsA, RA and AS. Obesity was significantly more common in PsA than in RA. In women, obesity, hypertension and multiple trad-CVRFs were more frequently reported in PsA than in RA and AS, whereas similar prevalence of CVRFs and coexistence of multiple trad-CVRFs were found in men with PsA, RA and AS.

Conclusions

Women and men with gout had the highest prevalence of trad-CVRFs. Differences in occurrence of CVRFs by sex were found in patients with PsA, RA and AS. In women, patients with PsA had higher occurrence of trad-CVRFs than those with RA and AS, whereas in men the distribution of CVRFs was similar in PsA, RA and AS.

Gout

Gout is a common and treatable disease caused by the deposition of monosodium urate crystals in articular and non-articular structures. Increased concentration of serum urate (hyperuricaemia) is the most important risk factor for the development of gout. Serum urate is regulated by urate transporters in the kidney and gut, particularly GLUT9 (SLC2A9), URAT1 (SLC22A12), and ABCG2. Activation of the NLRP3 inflammasome by monosodium urate crystals with release of IL-1β plays a major role in the initiation of the gout flare; aggregated neutrophil extracellular traps are important in the resolution phase. Although presenting as an intermittent flaring condition, gout is a chronic disease. Long-term urate lowering therapy (eg, allopurinol) leads to the dissolution of monosodium urate crystals, ultimately resulting in the prevention of gout flares and tophi and in improved quality of life. Strategies such as nurse-led care are effective in delivering high-quality gout care and lead to major improvements in patient outcomes.

Role of T cells in the pathogenesis and treatment of gout

Though macrophages and neutrophils are considered to be the principal immune cells involved in gout inflammation, recent studies highlight an emerging role of T cell subsets in the pathogenesis of gout. Some studies found that abnormal functions of several T cell subsets and aberrant expressions of their signature cytokines existed in gouty arthritis. Additionally, recent studies also suggested that therapeutic strategies by targeting pro-inflammatory T cell subsets or their related cytokines could ameliorate monosodium urate (MSU) crystals-induced arthritis in mice. The important role of T cells in gouty arthritis may provide some explanation for the absence of acute gout attacks among individuals with severe hyperuricemia or clinical evidence of MSU crystals deposition. Nevertheless, the molecular mechanisms underlying the role of those T cell subsets in gouty arthritis and their role in the initiation, progression and resolution of gouty arthritis are largely elusive, which need to be elaborated in future research. Uncovering the role of those T cell subsets in gout may transform our understanding of gout and facilitate new promising preventive or therapeutic strategies for gouty arthritis.

Sex Differences in the Clinical Profile Among Patients With Gout: Cross-sectional Analyses of an Observational Study

OBJECTIVE

Research findings in gout result predominantly from studies about men and might not be generalizable to women. To improve insight into sex differences in gout, our study compared clinical characteristics and comorbidities of female and male patients with gout, and explored the influence of menopause on these differences.

METHODS

Data from patients referred to 2 rheumatology clinics and diagnosed with gout were used. Clinical characteristics and comorbidities of each sex were compared univariately. Sex difference in comorbidities were further explored in multivariate logistic regression analyses adjusting for age, BMI, smoking, and alcohol consumption in both the total group and in those with gout onset ≥ 55 years (as a surrogate for menopausal state).

RESULTS

There were 954 patients, including 793 (83%) men, included. Women were on average older (65 vs 62 yrs), were more often obese (54% vs 36%), had a higher serum uric acid (sUA) level (0.53 vs 0.49 mmol/L), used diuretics more often (60% vs 30%), and consumed alcohol less frequently (47% vs 72%). Additionally, women more frequently had reduced renal function (64% vs 31%), hypertension (78% vs 56%), heart failure (23% vs 12%), and type 2 diabetes (39% vs 17%; all P < 0.05). In those with gout onset ≥ 55 years, differences in comorbidities were less pronounced and disappeared after adjusting for lifestyle.

CONCLUSION

Our study confirmed sex differences in clinical characteristics and comorbidities among newly diagnosed patients with gout, and revealed that sex differences in comorbidities among those with gout onset beyond the age of female menopause were strongly attenuated and fully explained by lifestyle.

Global epidemiology of gout: prevalence, incidence, treatment patterns and risk factors

Gout is the most common inflammatory arthritis and occurs when hyperuricaemia, sustained elevation of serum urate levels resulting in supersaturation of body tissues with urate, leads to the formation and deposition of monosodium urate crystals in and around the joints. Recent reports of the prevalence and incidence of gout vary widely according to the population studied and methods employed but range from a prevalence of <1% to 6.8% and an incidence of 0.58-2.89 per 1,000 person-years. Gout is more prevalent in men than in women, with increasing age, and in some ethnic groups. Despite rising prevalence and incidence, suboptimal management of gout continues in many countries. Typically, only a third to half of patients with gout receive urate-lowering therapy, which is a definitive, curative treatment, and fewer than a half of patients adhere to treatment. Many gout risk factors exist, including obesity, dietary factors and comorbid conditions. As well as a firmly established increased risk of cardiovascular disease and chronic kidney disease in those with gout, novel associations of gout with other comorbidities have been reported, including erectile dysfunction, atrial fibrillation, obstructive sleep apnoea, osteoporosis and venous thromboembolism. Discrete patterns of comorbidity clustering in individuals with gout have been described. Increasing prevalence and incidence of obesity and comorbidities are likely to contribute substantially to the rising burden of gout.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.