[Gout, beyond the joint: How should we treat it?]

Gout is a disease caused by the chronic deposition of monosodium urate crystals. Its clinical presentation as an acute, self-limiting arthritis and the belief that it is a banal, self-inflicted disease have led to its poor management. Despite advances in the knowledge of the disease and the simplicity of its management, no more than 30% of patients are well treated. In Spain, the prevalence of gout is 2.5% and its incidence is increasing. In the following article we will review the pathogenesis of gout and hyperuricaemia, highlighting the greater weight of genetics and renal function over diet. We will look at the consequences of crystal deposition. Gout, in addition to its joint presentation and renal involvement, has been shown to be an independent cardiovascular risk factor. Hypouricemic therapy is the most important treatment, as it is the one that dissolves the crystals and cures the disease. This requires the sustained achievement of uricemia levels below 6mg/dl. We will also review preventive and flares treatment, as well as the role of patient education in terms of both lifestyle and dietary habits and adherence to pharmacological treatment.

[Unusual case of pseudotumoral hip injury due to gout: case report]

Background

Gout is known as arthropathy due to the deposit of monosodium urate crystals; This pathology comprises a set of clinical and radiographic tests in the context of the intra-articular presence of said crystals. It is a chronic disease associated with other comorbidities such as arterial hypertension, osteoarthritis, diabetes mellitus, etc. The case of a patient with gouty arthritis with consequent hip lesion with a pseudotumoral appearance difficult to diagnose is presented, in order to highlight the importance of this, as well as the appropriate follow-up and treatment for this chronic pathology.

Clinical case

A 51-year-old male patient, with a history of hip osteoarthritis and gout. The symptoms and signs were pain in the right hip with an 8/10 on an analogue pain scale, associated with functional limitation characterized by reduced range of motion and impossibility of standing. Imaging studies are carried out which are suggestive of a tumor lesion at the proximal femur with malignant characteristics, for which a biopsy and subsequent histopathological diagnosis of gouty tophi is performed.

Conclusions

Gout is a prevalent disease in the adult population, however, its infrequent joint location can result in a difficult diagnosis, so it is necessary not to rule out this entity and to carry out specific studies for its identification.

Living with gout. Experiences, impact and challenges of the disease. Qualitative study through focus groups

OBJECTIVE

To delve into the experiences of people living with gout regarding its causes and triggers, recommended treatments and therapeutic measures, and the impact of living with this problem.

SUBJECTS AND METHODS

Descriptive qualitative study. Opinion sampling, looking for discursive variability according to sex, age, socioeconomic position and treatments. Three focus groups were made with 11, 6 and 7 people, following a pre-established script of topics. Analysis following thematic content analysis procedures.

RESULTS

Participants were 19 men and 5 women, of different ages, socioeconomic status and treatments. Frequent comorbidities: hypertension and hypercholesterolemia. Genetics and the lack of renal elimination of urate were mentioned as causes of gout. They reported little knowledge of the causes and need more explanations about them. As triggers of the attack they identified: excess food and/or alcohol, trauma, stress or not following the treatment. Various drug treatment and expressed concern about their possible adverse effects were listed. Difficulties in adherence to the recommendations were also described. Non-pharmacological measures: rest, cold, proper footwear, walking, drinking water, and diet were also described. Chronic gout has an important impact on the daily life of patients and their families. Pain invalidates and leads to difficulties in performing daily activities. Irritations and mood swings were reported, which affect their family relationships.

CONCLUSIONS

These findings provide proposals to improve the care of people with gout. Information on its causes, the triggers of the crisis, dietary recommendations and exercise should be improved. The variability of treatments and recommendations on lifestyle should be analysed in depth.

Analysis of musculoskeletal disorders-associated disability in Mexico from 1990 to 2021

BACKGROUND

Musculoskeletal disorders (MSD) affect 1.71 billion people worldwide and are the leading cause of disability.

OBJECTIVE

To analyze the years lived with disability (YLD) attributed to MSD in Mexico between 1990 and 2021.

MATERIAL AND METHODS

With estimates from the Global Burden of Disease 2021 study, the YLDs due to MSD and their six categories were analyzed, including osteoarthritis, rheumatoid arthritis, gout, neck pain, low back pain, as well as other MSDs. Patterns and trends in the number, crude rate, and YLD age-standardized rate were evaluated at the national and state levels, as well as by age group and gender.

RESULTS

MSDs were the main cause of YLDs in Mexico between 1990 and 2021, with an increase of 57.3%, going from 1,458.4 to 2,293.7 per 100,000 population. Low back pain (840.6 YLD) showed the highest rate in 2021, while osteoarthritis had the largest increase. MSDs increased with age and, and except for gout, affected women more often.

CONCLUSIONS

From 1990 to 2021, MSDs were the main cause of YLDs in Mexico, with a higher impact on adults and women. MSDs can appear early in life, hence the need for continuous interventions in order to preserve quality of life.

NRBP1 modulates uric acid transporter ABCG2 expression by activating the Wnt/β-catenin pathway in HK-2 cells

BACKGROUND

Nuclear receptor binding protein 1 (NRBP1) and ATP-binding cassette subfamily G member 2 (ABCG2) was the gout risk gene and high-capacity urate exporter respectively. However, the relationship between NRBP1 and ABCG2 and the underlying molecular mechanism contributing to these associations are unknown.

METHODS

Firstly, the efficiency of the overexpression and knockdown of NRBP1 was confirmed by western blot. Next, the effect of NRBP1 overexpression and knockdown on the expression of ABCG2, organic anion transporter 1 (OAT1), glucose transporter 9 (GLUT9) and urate transporter 1 (URAT1) was detected by qRT-PCR and western blot. At the same time, the cellular location of ABCG2 and its expression after NRBP1 overexpression and knockdown was tested by immunofluorescence (IF) staining. Then, the mechanism of NRBP1 modulates ABCG2 expression was evaluated by western blot with or without the β-catenin inhibitor (21H7).

RESULTS

The lentivirus system was used to generate stable NRBP1 overexpression, while the plasmids carrying a NRBP1 siRNA was generated to knockdown NRBP1 expression in HK-2 cells. Meanwhile, the overexpression of NRBP1 significantly decreased the mRNAs and proteins expression of GLUT9 and URAT1, while the knockdown of NRBP1 increased the mRNAs and proteins expression of ABCG2 significantly. In addition, the NRBP1 modulates the expression of ABCG2 was by ctivating the Wnt/β-catenin pathway in HK-2 cells according to the IF and western blot results.

CONCLUSION

Taken together, our study demonstrated that NRBP1 inhibition played an essential role in attenuating hyperuricemia and gout by upregulation of ABCG2 via Wnt/β-catenin signaling pathway in HK-2 cells.

Gout associated with reduced renal excretion of uric acid. Renal tubular disorder that nephrologists do not treat

Gout is recurrent inflammatory arthritis caused by the deposition of monosodium urate crystals in the joints. The risk factors that predispose to suffering from gout include non-modifiable factors such as gender, age, ethnicity and genetics, and modifiable factors such as diet and lifestyle. It has been shown that the heritability of uric acid levels in the blood is greater than 30%, which indicates that genetics play a key role in these levels. Hyperuricaemia is often a consequence of reduced renal urate excretion since more than 70% is excreted by the kidneys, mainly through the proximal tubule. The mechanisms that explain that hyperuricaemia associated with reduced renal urate excretion is, to a large extent, a proximal renal tubular disorder, have begun to be understood following the identification of two genes that encode the URAT1 and GLUT9 transporters. When they are carriers of loss-of-function mutations, they explain the two known variants of renal tubular hypouricaemia. Some polymorphisms in these genes may have an opposite gain-of-function effect, with a consequent increase in urate reabsorption. Conversely, loss-of-function polymorphisms in other genes that encode transporters involved in urate excretion (ABCG2, ABCC4) can lead to hyperuricaemia. Genome-wide association study (GWAS) methods have made it possible to locate new gout-related loci associated with reduced renal urate excretion (NIPAL1, FAM35A).

Gout. What's up doc?

A considerable improvement in the knowledge of gout has taken place in the 2decades of the XXIth century. Definitions of disease, estate, and clinical situations, along with a new nomenclature, have been agreed. More importantly, the concept of gout as a "curable" or "controllable" disease has been settled. We know for the first time its prevalence in Spain. Factors associated to disease, the genetics that condition the predisposition to develop hyperuricemia and the structure and functions of the transportome complex that control the renal and intestinal handling of urate have been examined. Imaging techniques have come to support diagnosis. Different primary therapeutic targets have been defined depending on the burden of disease, and targets for secondary prevention considered. We know how to best prescribe available medications and prevent the risk of adverse events. Finally, we have understood the importance of adherence, education, and empower patients during treatment instead of blaming them.

Perceived quality in patients with gout treated in a rheumatology clinic with a clinical nurse specialist

INTRODUCTION

Gout is a crystal arthropathy that is associated with significant loss of quality of life. A treat-to-target approach and proactive monitoring yield superior outcomes to standard care. The Clinical Nurse Specialist enhances follow-up and adherence to treatment in patients with gout, improving their perceived healthcare quality.

OBJECTIVE

To determine the factors that affect the perceived quality and satisfaction of patients with gout treated in a rheumatology clinic and to identify areas for improvement, as well as to explore the influence of nurses' work in the care and management of these patients.

METHODS

Cross-sectional observational study in patients with gout monitored in a monographic clinic by anonymous survey based on the SERVQUAL quality model, with demographic data and questions about aspects of care.

RESULTS

71 completed surveys were collected from the 80 delivered between August 2019 and January 2020. Most of the participants were males over 45 years of age. A total of 39% were satisfied with the care received, and 55% were very satisfied. All the respondents were satisfied with the face-to-face consultation with the Clinical Nurse Specialist and 66% considered the telephone consultation with the nurse to be good. Possible areas for improvement (referral time to consultation, identification, and availability of health providers) were identified.

CONCLUSION

We found high overall satisfaction perceived by the patients attended in a gout consultation with the Clinical Nurse Specialist. Understanding and systematizing the patients' opinion is essential to improve clinical care.

Gout associated with reduced renal excretion of uric acid. Renal tubular disorder that nephrologists do not treat

Gout is recurrent inflammatory arthritis caused by the deposition of monosodium urate crystals in the joints. The risk factors that predispose to suffering from gout include non-modifiable factors such as gender, age, ethnicity and genetics, and modifiable factors such as diet and lifestyle. It has been shown that the heritability of uric acid levels in the blood is greater than 30%, which indicates that genetics play a key role in these levels. Hyperuricaemia is often a consequence of reduced renal urate excretion since more than 70% is excreted by the kidneys, mainly through the proximal tubule. The mechanisms that explain that hyperuricaemia associated with reduced renal urate excretion is, to a large extent, a proximal renal tubular disorder, have begun to be understood following the identification of two genes that encode the URAT1 and GLUT9 transporters. When they are carriers of loss-of-function mutations, they explain the two known variants of renal tubular hypouricaemia. Some polymorphisms in these genes may have an opposite gain-of-function effect, with a consequent increase in urate reabsorption. Conversely, loss-of-function polymorphisms in other genes that encode transporters involved in urate excretion (ABCG2, ABCC4) can lead to hyperuricaemia. Genome-wide association study (GWAS) methods have made it possible to locate new gout-related loci associated with reduced renal urate excretion (NIPAL1, FAM35A).

Perceived Quality in Patients With Gout Treated in a Rheumatology Clinic With a Clinical Nurse Specialist

INTRODUCTION

Gout is a crystal arthropathy that is associated with significant loss of quality of life. A treat-to-target approach and proactive monitoring yield superior outcomes to standard care. The Clinical Nurse Specialist enhances follow-up and adherence to treatment in patients with gout, improving their perceived healthcare quality.

OBJECTIVE

To determine the factors that affect the perceived quality and satisfaction of patients with gout treated in a rheumatology clinic and to identify areas for improvement, as well as to explore the influence of nurses' work in the care and management of these patients.

METHODS

Cross-sectional observational study in patients with gout monitored in a monographic clinic by anonymous survey based on the SERVQUAL quality model, with demographic data and questions about aspects of care.

RESULTS

71 completed surveys were collected from the 80 delivered between August 2019 and January 2020. Most of the participants were males over 45years of age. A total of 39% were satisfied with the care received, and 55% were very satisfied. All the respondents were satisfied with the face-to-face consultation with the Clinical Nurse Specialist and 66% considered the telephone consultation with the nurse to be good. Possible areas for improvement (referral time to consultation, identification, and availability of health providers) were identified.

CONCLUSION

We found high overall satisfaction perceived by the patients attended in a gout consultation with the Clinical Nurse Specialist. Understanding and systematizing the patients' opinion is essential to improve clinical care.

Risk of osteoporotic thoracic vertebral fractures in patients with gout

OBJECTIVES

Osteoporosis causes significant morbidity and mortality by the development of fragility fractures, including vertebral fractures. Patients with gout may show an increased risk of osteoporotic fractures, as accelerated bone resorption is likely linked to urate crystal-led inflammatory state. This study aims to evaluate the risk of osteoporotic dorsal vertebral fractures associated with gout.

METHODS

Cross-sectional study carried out in patients admitted for cardiovascular events. Patients with available lateral view of chest radiography (on admission or in the previous six months) were selected. Two observers blinded to clinical data reviewed the radiographies simultaneously. Vertebral fracture was defined as a vertebral height loss ≥20%, and presence, number, and severity (by Genant semi-quantitative scale) were registered. To analyse the relationship between gout and the presence of vertebral fractures, the odds ratio (OR) with 95% confidence interval (95%CI) was calculated by multiple logistic regression.

RESULTS

126 patients were analysed, 21 of them (16.67%) suffered from gout. Eighteen cases with fractures were detected, with a prevalence of 14.3%. A significant association was found between gout and vertebral fracture (28.6% gout, 11.4% controls; OR 3.10, 95%CI 1.01-9.52). There were no differences in the number of fractures, while the severity was found to be higher in the controls. The association between gout and vertebral fracture persisted after multivariate adjustment (OR 5.21, 95% CI 1.32-20.61).

CONCLUSION

An independent association between gout and radiological thoracic vertebral fractures was revealed in patients with a cardiovascular event.

Risk of osteoporotic thoracic vertebral fractures in patients with gout

OBJECTIVES

Osteoporosis causes significant morbidity and mortality by the development of fragility fractures, including vertebral fractures. Patients with gout may show an increased risk of osteoporotic fractures, as accelerated bone resorption is likely linked to urate crystal-led inflammatory state. This study aims to evaluate the risk of osteoporotic dorsal vertebral fractures associated with gout.

METHODS

Cross-sectional study carried out in patients admitted for cardiovascular events. Patients with available lateral view of chest radiography (on admission or in the previous six months) were selected. Two observers blinded to clinical data reviewed the radiographies simultaneously. Vertebral fracture was defined as a vertebral height loss ≥20%, and presence, number, and severity (by Genant semi-quantitative scale) were registered. To analyse the relationship between gout and the presence of vertebral fractures, the odds ratio (OR) with 95% confidence interval (95%CI) was calculated by multiple logistic regression.

RESULTS

126 patients were analysed, 21 of them (16.67%) suffered from gout. Eighteen cases with fractures were detected, with a prevalence of 14.3%. A significant association was found between gout and vertebral fracture (28.6% gout, 11.4% controls; OR 3.10, 95%CI 1.01-9.52). There were no differences in the number of fractures, while the severity was found to be higher in the controls. The association between gout and vertebral fracture persisted after multivariate adjustment (OR 5.21, 95% CI 1.32-20.61).

CONCLUSION

An independent association between gout and radiological thoracic vertebral fractures was revealed in patients with a cardiovascular event.

Gouty Involvement of Foot and Ankle: Beyond Flares

The foot and ankle are common locations of deposition of monosodium urate (MSU) crystals, as indicated by the clinical manifestations presented by patients with gout, which are not limited to the acute inflammation of the big toe. We present a narrative literature review aimed to update the gout involvement of foot and ankle and how it affects the quality of life. Cumulative reports indicate that gout, even at the non-tophaceous stage, could cause pain, gait impairment and limit the mobility at lower limbs. These patients may present difficulties in some activities of daily living such as choosing footwear, thus leading to an impaired quality of life. Gout is a curable disease by dissolving MSU crystals but remains unclear how this could modify some of these foot and ankle manifestations, especially when structural damage has already occurred. Furthermore, a collaboration between rheumatologists and podiatrists seems helpful to understand, relieve these symptoms and improve the quality of life in gouty patients.

Prevalence of rheumatic diseases in adult population in Spain (EPISER 2016 study): Aims and methodology

AIMS

To describe the methodology of the EPISER 2016 (study of the prevalence of rheumatic diseases in adult population in Spain), as well its strengths and limitations. The aim of this study is to estimate the prevalence of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), Sjögren's syndrome (SS), osteoarthritis (knee, hip, hands, and cervical and lumbar spine), fibromyalgia, gout and clinical osteoporotic fracture.

MATERIAL AND METHOD

Population-based, multicenter, cross-sectional study, with the participation of 45 municipalities in the 17 Spanish autonomous communities. The reference population will consist of adults aged 20 years and over residing in Spain. A computer-assisted telephone interview (CATI) system will be used for data collection. Diagnostic suspicions and diagnoses received by the participants will be studied by rheumatologists in the referral hospitals in the selected municipalities.

STATISTICAL ANALYSIS

the prevalence of the rheumatic diseases will be calculated using estimators and their 95% confidence intervals. Weights will be calculated in each of the sampling stages in accordance with the probability of selection. The distribution of the population in Spain will be obtained from the Spanish Statistics Institute.

CONCLUSIONS

Sociodemographic and lifestyle changes over the last 16 years justify EPISER 2016. This study will provide current data about the prevalences of RA, AS, PsA, SLE, SS, osteoarthritis, fibromyalgia, gout and clinical osteoporotic fracture. The results will allow comparisons with studies from other countries and EPISER 2000.

Critical revision of the medical treatment of gout in Brazil

Gout is considered the most common form of inflammatory arthritis in men over 40 years. The authors present a brief review of the current treatment of gout and discuss the existing pharmacological limitations in Brazil for the treatment of this disease. Although allopurinol is still the main drug administered for decreasing serum levels of uric acid in gout patients in this country, the authors also present data that show a great opportunity for the Brazilian drug market for the treatment of hyperuricemia and gout and especially for patients using private and public (SUS) health care systems.

Relevant aspects of imaging in the diagnosis and management of gout

Gout is an inflammatory arthritis characterized by the deposition of monosodium urate crystals in the synovial membrane, articular cartilage and periarticular tissues leading to inflammation. Men are more commonly affected, mainly after the 5th decade of life. Its incidence has been growing with the population aging. In the majority of the cases, the diagnosis is made by clinical criteria and synovial fluid analysis, in search for monosodium urate crystals. Nonetheless, gout may sometimes have atypical presentations, complicating the diagnosis. In these situations, imaging methods have a fundamental role, aiding in the diagnostic confirmation or excluding other possible differential diagnosis. Conventional radiographs are still the most commonly used method in gout patients' evaluation; nevertheless, this is not a sensitive method, since it detect only late alterations. In the last years, there have been several advances in imaging methods for gout patients. Ultrasound has shown a great accuracy in the diagnosis of gout, identifying monosodium urate deposits in the synovial membrane and articular cartilage, in detecting and characterizing tophi and in identifying tophaceous tendinopathy and enthesopathy. Ultrasound has also been able to show crystal deposition in patients with articular pain in the absence of a classical gout crisis. Computed tomography is an excellent method for detecting bone erosions, being useful in spine involvement. Dual-energy CT is a new method able to provide information about the chemical composition of tissues, with high accuracy in the identification of monosodium urate deposits, even in the early stages of the disease and in cases of difficult characterization. Magnetic resonance imaging is useful in the evaluation of deep tissues not accessible by ultrasound. Besides the diagnosis, with the emergence of new drugs that aim to reduce tophaceous burden, imaging methods have become useful tools in monitoring the treatment of patients with gout.

Systematic review of the value of ultrasound and magnetic resonance musculoskeletal imaging in the evaluation of response to treatment of gout

BACKGROUND

Imaging may be useful for monitoring response to therapy. Within the OMERACT proposal for the core set domains for outcome measures in chronic gout, serum urate levels, recurrence of gouty flares, tophus regression, and joint damage imaging have been included, among other proposed issues.

OBJECTIVES

To perform a systematic literature review of the usefulness of magnetic resonance imaging (MRI) and ultrasound (US) on assessment of treatment response in patients with gout.

METHODS

MEDLINE, EMBASE, Cochrane Library (up to February 2012), and abstracts presented at the 2010 and 2011 meetings of the American College of Rheumatology and European League Against Rheumatism, were searched for treatment studies of any duration and therapeutic options, examining the ability of MRI/US to assess treatment response in gouty patients. Meta-analyses, systematic reviews, randomized clinical trials, cohort and case-control studies and validation studies were included. Quality was appraised using validated scales.

RESULTS

There were only 3 US published studies in the literature that analysed US utility on assessment of response to treatment in patients with gout. All of them were prospective case studies with a small number of patients and they were reviewed in detailed. A total of 36 patients with gout were examined with US. All of them had a baseline serum urate >6mg/dL. US features of gout (double contour sign, hyperechoic spots in synovial fluid, hyperechoic cloudy areas, tophus diameter and volume) achieved significant reduction in patients who reached the objective of uricemia ≤6mg/dL in all the studies; however, patients in whom levels did not drop below 6mg/dL had no change of US features of gout. Other parameters evaluated in one study included ESR, CRP, number of tender joints (TRN), number of swollen joints, and pain score (SP). All of them decreased with uricemia reduction, but only TRN and SP were statistically significant. No data was found on the value of MRI on treatment response assessment in patients with gout.

CONCLUSIONS

The improvement in ultrasound features shows concurrent validity with uric acid reduction. According to the published evidence, US can be a useful tool for monitoring treatment of gouty patients, although more research is needed. The value of MRI on treatment response assessment in patients with gout remains to be determined.