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Managing gout in 2024 – are you up to date?

26 June 2024 - Dr Kate Annear

Gout, also known as crystal arthritis or gouty arthritis, is a chronic condition characterised by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints. The first attack is often monoarticular, most often the big toe (first metatarsophalangeal joint).[1]

It is one of the most common inflammatory joint diseases globally and locally, and presents a significant burden for many people in Australia.[2] Self-reported prevalence rates are between 4.5% and 6.8% and it is more common among males and certain ethnic groups.[2] 

Despite its high prevalence, gout is often undertreated, contributing to significant avoidable pain, disability and impaired quality of life for affected individuals.[3,4] Additionally, the stigma associated with the disease may be preventing patients from seeking treatment in the first place or continuing with treatment once diagnosed.[5,6]

This article addresses several misconceptions about gout that have been identified as affecting the delivery of care.

Gout is a chronic disease 

Gout is sometimes perceived as an acute condition, associated with an ‘attack’ that causes temporary pain and discomfort but is otherwise harmless. However, it is a serious chronic disease and its severity is often underestimated. If left untreated, high serum urate levels can lead to joint damage, tophi and kidney disease. Effective management is essential to prevent these complications.

Gout is not just an ‘old man’s’ disease

Gout is often viewed as a disease that only affects older males. While it is more prevalent in this demographic, gout can affect anyone, including females, particularly post-menopause, and younger adults, especially those with certain genetic predispositions or other risk factors. 

How gout presents in some populations may also be less typical. In females, for example, the first acute attack may be polyarticular and is often seen in the hands.[1] 

Health professionals should not risk a delay in diagnosis because the presenting patient is not considered a ‘textbook’ gout patient. 

Urate-lowering therapy is not set and forget

Urate-lowering therapy (ULT) is the cornerstone of gout management, yet local and international evidence shows it is underutilised.[7–9] The Australian Therapeutic Guidelines recommend prescribing lifelong ULT using a treat-to-target approach, to prevent further acute attacks and disease progression.[1] 

Once ULT is initiated, the dose should be uptitrated (monthly), until target serum urate levels are reached, and then monitored regularly (at 6 months, then annually).  In addition, flare prophylaxis is recommended for all patients starting ULT (or when increasing the dose). Prophylaxis should be continued until the patient has no further attacks and the target serum urate concentration has been achieved. This usually takes at least 6 months.[1] 

Current research suggests that low uptake of a treat-to-target approach (including appropriate serum urate monitoring) and lack of adequate prophylaxis during initiation may contribute to poor adherence and lack of confidence in treatment by patients.[10,11] 

The role of diet is smaller than you think

It is a common misconception that gout is solely caused by lifestyle factors, such as poor diet and excessive alcohol consumption. While it’s true that diet can influence uric acid levels, this is only part of the picture. Gout is primarily a metabolic disorder influenced by genetic predisposition. Impaired renal function and obesity also significantly contribute to hyperuricaemia. Diet and lifestyle can trigger a gout flare but are not the root cause. 

It is important to correct perceptions of gout being a self-inflicted, ‘lifestyle’ disease. Such beliefs have been shown to delay people seeking help because of shame, guilt or embarrassment.[10,11]

People living with gout should be encouraged to eat a healthy balanced diet, with a focus on increasing their consumption of fruits, vegetables and low-fat dairy, and reducing the consumption of purine-rich foods associated with triggering gout flares (such as red meat and shellfish) and limiting alcohol (particularly beer and spirits) or fructose-sweetened beverages. Adequate hydration with water and skim milk can help support kidney health and elimination of uric acid.[12]

As health professionals, it’s our responsibility to provide evidence-based care that addresses current common misconceptions. Gout can be a challenging condition that requires a comprehensive management approach, combining ULT with appropriate lifestyle modifications. By addressing both pharmacologic and non-pharmacologic factors, we can improve patient outcomes and quality of life.

  

Dr Kate Annear, Sydney GP and Medical Adviser, Medcast.

A national program approach

Person-centred management is at the centre of the gout program from the Quality Use of Medicines Alliance. We have conducted extensive formative research to better understand the factors that currently impact gout care in Australia and combined these learnings with a robust co-design process. 

Working with people with lived experience of gout and the health professionals that care for them, we have developed a range of education activities and practical resources that work to address the misconceptions described above.

Key features of our program include virtual educational visiting, webinars and peer-group learning activities, podcasts and videos. To support decision-making and empower self-care management by patients and their carers, a suite of clinical practice and consumer resources will also be available.

To find out more visit QHub.

This clinical update is brought to you by Medcast and the Quality Use of Medicines Alliance. 

 

For more free Quality Use of Medicines education, check out QHUB on Medcast


References

1. Therapeutic Guidelines. Gout. Therapeutic Guideline Ltd.Melbourne 2021.  Accessed 11 June 2024. https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Rheumatology&topicfile=gout

2. Pathmanathan K, Robinson PC, Hill CL,  Keen HI. The prevalence of gout and hyperuricaemia in Australia: An updated systematic review. Sem Arthr Rheum 2021: 51(1); 121–128. https://doi.org/10.1016/j.semarthrit.2020.12.001

3. Coulshed A, Nguyen AD, Stocker SL, Day RO. Australian patient perspectives on the impact of gout. Int J Rheum Dis 2020: 23(10); 1372–1378. https://doi.org/10.1111/1756-185X.13934

4. Sinnappah KA, Stocker SL, Chan JS, et al. Clinical interventions to improve adherence to urate-lowering therapy in patients with gout: A systematic review. Int J Pharm Pract 2022: 30(3); 215–225. https://doi.org/10.1093/ijpp/riac025

5. Afinogenova Y, Danve A, Neogi T. Update on gout management: What is old and what is new. Curr Opin Rheum 2022: 34(2); 118–124. https://doi.org/10.1097/BOR.0000000000000861

6. Kleinstäuber M, Wolf L, Jones ASK, et al. Internalized and Anticipated Stigmatization in Patients With Gout. ACR Open Rheumatol. 2020;2(1):11-17. doi: 10.1002/acr2.11095.

7. Coleshill MJ, Day RO, Tam K., et al. Persistence with urate-lowering therapy in Australia: A longitudinal analysis of allopurinol prescriptions. Brit J Clin Pharmacol 2022: 88(11); 4894–4901. https://doi.org/10.1111/bcp.15435

8. Nguyen AD, Lind KE, Day RO, et al. Measuring quality of gout management in residential aged care facilities. Rheumatol Adv Prac 2022: 6(3); rkac091. https://doi.org/10.1093/rap/rkac091

9. Jeyaruban A, Larkins S, Soden M. Management of gout in general practice—A systematic review. Clin Rheum 2015: 34(1); 9–16. https://doi.org/10.1007/s10067-014-2783-z

10. Spragg JCJ, Michael TJF, Aslani P, et al. Optimizing adherence to allopurinol for gout: Patients’ perspectives. Brit J Clin Pharmacol 2023: 89(7); 1978–1991. https://doi.org/10.1111/bcp.15657

11. Kong DCH, Sturgiss EA, Dorai Raj A K, Fallon K. What factors contribute to uncontrolled gout and hospital admission? A qualitative study of inpatients and their primary care practitioners. BMJ Open 2019: 9(12); e033726. https://doi.org/10.1136/bmjopen-2019-033726

12. Major TJ, Topless RK, Dalbeth N,  Merriman TR. Evaluation of the diet wide contribution to serum urate levels: Meta-analysis of population based cohorts. BMJ 2018: k3951. https://doi.org/10.1136/bmj.k3951

Dr Kate Annear
Dr Kate Annear
Dr Kate Annear MBBS(Hons), DCH, MPH, FRACGP is an experienced GP based in Sydney, specialising in women's and children's health. She has a special interest in public health and medical education. Kate is the clinical lead for all health professional education on QHUB for the QUDTP project. 
Kate was previously a Medical Advisor at NPS MedicineWise where she was involved in the development and implementation of projects including the safe use of medicines for older people and chronic kidney disease. Kate is experienced in hosting webinars and podcasts exploring issues related to the quality use of medicines.
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