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Gout - it's no laughing matter

Published on 01 July 2010
Source: Arthritis Today

Punch Cures the Gout, the Colic and the Tisic – Gillray’s famous gout cartoon

 If gout can be cured, why is it on the increase and why are so many people still suffering? A new Arthritis Research UK study may shed some light on why gout is still about – and how it can be treated more effectively. Jane Tadman reports.   

Gout expert Mike Doherty has a theory about why gout is not taken as seriously as it should be – both by the medical profession and the general public.

“As far back as the famous Gillray cartoon gout has been seen as a bit of a joke – the idea of a grown man crying his eyes out because of pain in his toe,” he says. “People can’t take it seriously. Everyone laughs at gout. But no-one laughs at rheumatoid arthritis.”

Gout is in fact the commonest inflammatory form of arthritis in the UK, affecting 1.4 per cent of the population (compared to rheumatoid arthritis, which affects 0.8 per cent). Caused by a build-up of sodium urate crystals in the joints: usually the feet, knees, wrists, fingers and elbows – it is, say sufferers, the most excruciating pain that can be experienced, on a par with childbirth.

Globally, gout is on the increase, largely due to the accompanying rise in so-called metabolic disorders – obesity, high blood pressure, high cholesterol, and type-2 diabetes, all of which are risk factors. It’s also strongly associated with osteoarthritis; also known to be on the up, as the world’s population ages and
gets fatter.

“Another reason for the increase in prevalence is that we are living longer and gout is an age-related problem,” says Mike Doherty, Professor of Rheumatology at The University of Nottingham. “It’s also because there is more osteoarthritis around, as urate crystals tend to deposit in osteoarthritic joints.”

He takes the view that specific dietary factors are not the key risk as is commonly supposed, citing obesity and genetic factors as being more important. “Two thirds of uric acid comes from your body making uric acid – so the bigger your body the more uric acid you make. Only one third of uric acid in the body comes from diet. So although diet can have some influence – if you have a diet that is very rich in purines, so for example eating steaks five days a week out of seven and drinking large amounts of beer, I think we need to focus more on diets that overall increase obesity and play down individual factors such as shellfish and offal. People who get gout often inherit it, or have inherited inefficient kidneys, which means that uric acid isn’t processed properly in the body.”

Professor Mike Doherty

Recent European guidelines are clear that if gout is treated properly it should result in the condition being “cured.” So if this is the case, why do people have it in increasing numbers? The answer almost certainly is that it is not treated either properly or adequately in primary and secondary care.
There are two main ways to manage gout – the first is to treat an acute attack, and the second is to miminise the likelihood of further attacks by prescribing long-term medication to rid the body of urate crystals in the joints and to prevent new crystals forming.

Unfortunately, many GPs concentrate more on treating an acute attack.

A glance at the UKGP Database reveals that fewer than one in three people with gout is on long-term medication – such as allopurinol – to lower the urate levels in their blood. Two-thirds are not. Again, in a community audit in Nottingham, fewer than one in three people with gout was on uratelowering drugs, and half of these were not on high enough doses.

“GPs focus on an acute attack and they don’t have a mental picture of what a person’s joints may look like in ten years’ time,” says Professor Doherty. “It’s insufficiently realised that gout is a chronic progressive disease that can cause irreversible joint damage.

"Patients are often blamed for stopping taking their long-term medication because they can’t see any point or benefit. But it’s all about how you give people the right information. I’ve never had anyone say they didn’t want urate-lowering drugs once I have explained the alternative.”

Clinical guidelines state that once patients have recurrent attacks of gout, or if they already have evidence of joint damage or obvious swellings of compacted crystals under the skin ('tophi') they should be put on longterm medication to dissolve away the crystals and prevent new ones forming. If left untreated the acute attacks will continue to occur, becoming more frequent and severe. Allopurinol is the usual first urate-lowering drug to use. It should be started at 100mg a day, then increased every four weeks or so, 100mg at a time, until the patient’s serum uric acid levels have been reduced to a low at which it is impossible to form urate crystal. If the uric acid is kept at a low level, the urate crystals will be dissolved away within about one to two years of treatment. This is known as hitting the therapeutic target. But most GPs start patients on a fixed 300mg standard dose and don’t check their patient’s urate levels again; so the urate levels don’t drop, the patient notices no benefit, and stops taking the drugs because they don’t think they’re working.

What can be done about this unsatisfactory state of affairs?

Arthritis Research UK is currently funding Professor Doherty and his team to carry out a year-long proof-ofconcept study to treat 100 gout patients who have previously received less than ideal care. If 70 per cent of them reach their therapeutic target and their urate levels drop accordingly, the study will proceed to a full-scale clinical trial.

The trial, to be run by specialist gout nurses, will aim to develop a practical and acceptable treatment package for gout patients in the GP surgery, where most patients are treated. While one group of patients receive the usual GP care, the other will receive the nurseled care with advice on how to change and improve their diet and lose weight. This group will also be put on an increasing dose of allopurinol or other urate lowering drugs (such as a new drug, febuxostat), as recommended by current European and UK guidelines. In a linked qualitative study patients will complete questionnaires about their medical history, treatment and quality of life.

Mike Doherty believes that the trial to test best practice in gout treatment could have far reaching implications for long-suffering gout patients. "We need to change perceptions, among both GPs and patients, about gout. This study will lead to the first randomised controlled trial that aims to “cure” gout by applying currently available treatments. We have effective treatments but they’re not being used as well as they should be," he says. "There’s a view that gout has been dealt with, but as many gout sufferers will tell you, it hasn’t. We’re not doing as well as we should be doing as a medical profession. Taking gout seriously would be a good start."

Did you know?

  • Sometimes starting allopurinol at the standard dose can spark off attacks of gout – so it’s better to start off with a lower dose
  • Gout affects three to four times as many men as women
  • Gout is the most common inflammatory form of arthritis in men, and the commonest form of inflammatory arthritis in postmenopausal women
  • A new urate-lowering drug for gout called febuxostat is now available and is particularly suitable for people with kidney problems 

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