Patient and provider barriers to effective management of gout in general practice: a qualitative study

OBJECTIVES

To explore patient and provider illness perceptions and barriers to effective management of gout in general practice.

DESIGN AND SETTING

A qualitative study involving semistructured face-to-face interviews with patients and health professionals from 25 Nottinghamshire general practices and one central National Health Service hospital.

PARTICIPANTS

Twenty gout sufferers and 18 health professionals (six general practitioners, five hospital physicians, seven practice nurses).

RESULTS

A number of key themes emerged suggesting that several factors impact on patients' access to recommended treatments. The main barriers were patient experiences and lay beliefs of their condition which affected seeking advice and adherence to treatment. There was universal lack of knowledge and understanding of the causes and consequences of gout and that it can be treated effectively by lifestyle change and use of urate lowering therapy (ULT). All participants associated gout with negative stereotypical images portrayed in Victorian cartoons. Many viewed it as self-inflicted or part of ageing and only focused on managing acute attacks rather than treating the underlying cause. The main provider barriers that emerged related to health professionals' lack of knowledge of gout and management guidelines, reflected in the suboptimal information they gave patients and their reluctance to offer ULT as a 'curative' long-term management strategy.

CONCLUSION

There are widespread misconceptions and lack of knowledge among both patients and health professionals concerning the nature of gout and its recommended management, which leads to suboptimal care of the most common inflammatory joint disease and the only one for which we have 'curative' treatment.

Association of variants at UMOD with chronic kidney disease and kidney stones-role of age and comorbid diseases

Chronic kidney disease (CKD) is a worldwide public health problem that is associated with substantial morbidity and mortality. To search for sequence variants that associate with CKD, we conducted a genome-wide association study (GWAS) that included a total of 3,203 Icelandic cases and 38,782 controls. We observed an association between CKD and a variant with 80% population frequency, rs4293393-T, positioned next to the UMOD gene (GeneID: 7369) on chromosome 16p12 (OR = 1.25, P = 4.1×10⁻¹⁰). This gene encodes uromodulin (Tamm-Horsfall protein), the most abundant protein in mammalian urine. The variant also associates significantly with serum creatinine concentration (SCr) in Icelandic subjects (N = 24,635, P = 1.3×10⁻²³) but not in a smaller set of healthy Dutch controls (N = 1,819, P = 0.39). Our findings validate the association between the UMOD variant and both CKD and SCr recently discovered in a large GWAS. In the Icelandic dataset, we demonstrate that the effect on SCr increases substantially with both age (P = 3.0×10⁻¹⁷) and number of comorbid diseases (P = 0.008). The association with CKD is also stronger in the older age groups. These results suggest that the UMOD variant may influence the adaptation of the kidney to age-related risk factors of kidney disease such as hypertension and diabetes. The variant also associates with serum urea (P = 1.0×10⁻⁶), uric acid (P = 0.0064), and suggestively with gout. In contrast to CKD, the UMOD variant confers protection against kidney stones when studied in 3,617 Icelandic and Dutch kidney stone cases and 43,201 controls (OR = 0.88, P = 5.7×10⁻⁵).

Chronic kidney disease (CKD) is a common condition that is associated with substantial morbidity and mortality and has been recognized as a major public health problem worldwide. Common causes of CKD include hypertension, diabetes, and inflammatory disorders. Previous studies have shown a significant genetic contribution to kidney disease and a recent genome-wide association study yielded a variant in the UMOD gene that affects the risk of CKD. Here, we replicate the association between UMOD and CKD in an independent analysis. We also demonstrate for the first time an interaction between the UMOD variant and age that suggests that this variant may adversely affect the aging kidney and its adaptation to age-related risk factors of kidney disease, such as hypertension and diabetes. Furthermore, we show that the UMOD variant that affects risk of CKD also provides protection against kidney stone disease.

Uric acid in metabolic syndrome: Does uric acid have a definitive role?

Increased serum uric acid (SUA) levels are commonly seen in patients with metabolic syndrome and are widely accepted as risk factors for hypertension, gout, non-alcoholic fatty liver disease, chronic kidney disease (CKD), and cardiovascular diseases. Although some ambiguity for the exact role of uric acid (UA) in these diseases is still present, several pathophysiological mechanisms have been identified such as increased oxidative stress, inflammation, and apoptosis. Accumulating evidence in genomics enlightens genetic variabilities and some epigenetic changes that can contribute to hyperuricemia. Here we discuss the role of UA within metabolism and the consequences of asymptomatic hyperuricemia while providing newfound evidence for the associations between UA and gut microbiota and vitamin D. Increased SUA levels and beneficial effects of lowering SUA levels need to be elucidated more to understand its complicated function within different metabolic pathways and set optimal target levels for SUA for reducing risks for metabolic and cardiovascular diseases.

Uric acid and the cardio-renal effects of SGLT2 inhibitors

Sodium/glucose co-transporter-2 (SGLT2) inhibitors, which lower blood glucose by increasing renal glucose elimination, have been shown to reduce the risk of adverse cardiovascular (CV) and renal events in type 2 diabetes. This has been ascribed, in part, to haemodynamic changes, body weight reduction and several possible effects on myocardial, endothelial and tubulo-glomerular functions, as well as to reduced glucotoxicity. This review evaluates evidence that an effect of SGLT2 inhibitors to lower uric acid may also contribute to reduced cardio-renal risk. Chronically elevated circulating uric acid concentrations are associated with increased risk of hypertension, CV disease and chronic kidney disease (CKD). The extent to which uric acid contributes to these conditions, either as a cause or an aggravating factor, remains unclear, but interventions that reduce urate production or increase urate excretion in hyperuricaemic patients have consistently improved cardio-renal prognoses. Uric acid concentrations are often elevated in type 2 diabetes, contributing to the "metabolic syndrome" of CV risk. Treating type 2 diabetes with an SGLT2 inhibitor increases uric acid excretion, reduces circulating uric acid and improves parameters of CV and renal function. This raises the possibility that the lowering of uric acid by SGLT2 inhibition may assist in reducing adverse CV events and slowing progression of CKD in type 2 diabetes. SGLT2 inhibition might also be useful in the treatment of gout and gouty arthritis, especially when co-existent with diabetes.

THE EPIDEMIOLOGY OF RHEUMATIC DISEASES

Images

ON THE ACTION OF COLCHICINE, THE MELANOCYTE MODEL

The effect of colchicine was studied on the rapid, reversible darkening of frog skin under the influence of melanocyte-stimulating hormone (MSH). Darkening is due to dispersion of melanin granules in melanocytes and is thought to be accompanied by a gel-to-sol cytoplasmic transformation. After subsequent washing, the skin lightens, with aggregation of melanin granules and cytoplasmic gelation. Preincubation of skin with colchicine had the following effects: 1. Darkening induced by MSH was increased in comparison to control skins, and on removal of MSH, lightening was inhibited. Inhibition was a function of both concentration (1 x 10^–5 to 9 x 10^–5M) and exposure time (2 to 30 minutes). Once established, inhibition was maintained throughout the remainder of the experiment. 2. The same effects were noted (a) when darkening was effected by agents other than MSH (ATP) 0.9 x 10^–3M; caffeine, 5.2 x 10^–3M; ethyl acetate, 0.8 x 10^–2M), and (b) when lightening was effected by addition of chemical agents (melatonin, 4.3 x 10^–10M; hydrocortisone, 1 x 10^–3M; norepinephrine, 1 x 10^–3M), instead of by washing. 3. Colchicine alone produced a gradual, irreversible, dosage-dependent darkening over several hours. This darkening was inhibited by melatonin, 4.3 x 10^–10M. The melanocyte model is used to construct a general theory of colchicine action on living cells, an action resulting in decreased protoplasmic viscosity. In this formulation colchicine lowers the potential limit of protoplasmic gelation, and does it rapidly, reversibly, in low concentration, in a dosage-dependent manner, and without killing the cell. The theory allows interpretation of "synergism" and "antagonism" to colchicine by other substances. It suggests a tentative approach to the understanding of colchicine action in acute gouty arthritis, where interference with ameboid activities of polymorphonuclear leukocytes is one possible aspect of the anti-inflammatory effect of colchicine. Finally, the colchicine-treated melanocyte is viewed as a good, live physical model that can be used to elucidate some fundamental biological properties.

Alterations of uromodulin biology: a common denominator of the genetically heterogeneous FJHN/MCKD syndrome

Autosomal dominant hyperuricemia, gout, renal cysts, and progressive renal insufficiency are hallmarks of a disease complex comprising familial juvenile hyperuricemic nephropathy and medullary cystic kidney diseases type 1 and type 2. In some families the disease is associated with mutations of the gene coding for uromodulin, but the link between the genetic heterogeneity and mechanism(s) leading to the common phenotype symptoms is not clear. In 19 families, we investigated relevant biochemical parameters, performed linkage analysis to known disease loci, sequenced uromodulin gene, expressed and characterized mutant uromodulin proteins, and performed immunohistochemical and electronoptical investigation in kidney tissues. We proved genetic heterogeneity of the disease. Uromodulin mutations were identified in six families. Expressed, mutant proteins showed distinct glycosylation patterns, impaired intracellular trafficking, and decreased ability to be exposed on the plasma membrane, which corresponded with the observations in the patient's kidney tissue. We found a reduction in urinary uromodulin excretion as a common feature shared by almost all of the families. This was associated with case-specific differences in the uromodulin immunohistochemical staining patterns in kidney. Our results suggest that various genetic defects interfere with uromodulin biology, which could lead to the development of the common disease phenotype. 'Uromodulin-associated kidney diseases' may be thus a more appropriate term for this syndrome.

The impact of gout on work absence and productivity

OBJECTIVE

The goal of this analysis was to evaluate the impact of gout, a painful inflammatory arthritis condition, on an employed population's health-related work absence and objectively measured productivity output.

METHODS

Payroll, demographic, medical, pharmaceutical, sick leave, short- and long-term disability, and workers' compensation data were collected from multiple large employers with employees widely dispersed across the United States. Data were collected during the time period of 2001 to 2004 from approximately 300,000 employees. Objective productivity output data were also available for a subset of employees (captured electronically in the form of units of work processed per person). T-tests and chi-square tests were used to compare demographic data. Two-stage multivariate regression models were used to compare annual work absence and at-work productivity between employees with and without gout, while controlling for group differences in demographics, salary, other work-related variables, and comorbidities (using the Charlson Comorbidity Index).

RESULTS

The annual prevalence of gout was 4.7 per 1000 employees from 2001 to 2004. Employees with gout had 4.56 more annual absence days for all categories of health-related work absence than those without gout. Objective productivity (units of work processed) results were only available for a small subsample of employees (86 with gout and 27,472 without gout). Employees with gout processed 3.51% fewer units per hour worked and 2.38% fewer units per year than employees without gout (nonsignificant at P = 0.49 and P = 0.78, respectively).

CONCLUSION

This study suggests that gout has a substantial impact on work absence and may also negatively impact productivity.

HYPERTRIGLYCERIDEMIA IN GOUT

Serum triglyceride levels were significantly higher in 34 patients with gout (42 mg. per 100 ml.) in comparison to the levels in 28 healthy men over 35 years of age (100 mg. per 100 ml.). There was no significant predictive relation between levels of serum uric acid and triglycerides in either group. No significant difference in serum cholesterol levels nor lipoprotein profile was apparent between the two groups. The patients with gout had been selected to exclude any manifestations of atherosclerosis or other disease known to be associated with abnormalities in circulating lipids. The results provide support for possible linkage of genetic factors influencing uric acid and triglyceride metabolism. The presence of hypertriglyceridemia in gout may be correlated with the increased incidence of arteriosclerosis.

Alcohol consumption and risks of more than 200 diseases in Chinese men

Alcohol consumption accounts for ~3 million annual deaths worldwide, but uncertainty persists about its relationships with many diseases. We investigated the associations of alcohol consumption with 207 diseases in the 12-year China Kadoorie Biobank of >512,000 adults (41% men), including 168,050 genotyped for ALDH2- rs671 and ADH1B- rs1229984 , with >1.1 million ICD-10 coded hospitalized events. At baseline, 33% of men drank alcohol regularly. Among men, alcohol intake was positively associated with 61 diseases, including 33 not defined by the World Health Organization as alcohol-related, such as cataract (n = 2,028; hazard ratio 1.21; 95% confidence interval 1.09-1.33, per 280 g per week) and gout (n = 402; 1.57, 1.33-1.86). Genotype-predicted mean alcohol intake was positively associated with established (n = 28,564; 1.14, 1.09-1.20) and new alcohol-associated (n = 16,138; 1.06, 1.01-1.12) diseases, and with specific diseases such as liver cirrhosis (n = 499; 2.30, 1.58-3.35), stroke (n = 12,176; 1.38, 1.27-1.49) and gout (n = 338; 2.33, 1.49-3.62), but not ischemic heart disease (n = 8,408; 1.04, 0.94-1.14). Among women, 2% drank alcohol resulting in low power to assess associations of self-reported alcohol intake with disease risks, but genetic findings in women suggested the excess male risks were not due to pleiotropic genotypic effects. Among Chinese men, alcohol consumption increased multiple disease risks, highlighting the need to strengthen preventive measures to reduce alcohol intake.