Call to arms on gout forecast

Case numbers are tipped to explode around the world, including in Australasia, in coming decades.

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The number of people with gout has doubled internationally to almost 56 million, and that number is expected to rise by more than 70% by 2050, new figures from the Global Burden of Disease study have revealed.

The news, published in The Lancet last month, was particularly sobering for Australia and its neighbours. Sydney rheumatologist and clinical pharmacologist Professor Ric Day said the forecast explosion in gout cases over the next 25 years needed urgent action.

“It is a bit of a call to arms for rheumatologists and metabolic physicians, because of the overlap now with cardiovascular, renal, diabetes, gout and also the overlap of medications that deal with all of them at once – for example, the SGLT-2 inhibitors, and also the GLP-1 inhibitors as well,” he told The Medical Republic.

“All of those are right in play now for this metabolic syndrome and they have benefits, particularly SGLT-2s, for gout per se, as well as heart, diabetes and kidney [health].”

The Australasian region’s age-standardised prevalence of gout in 2020 was more than double the global average and the second highest in the world at 1423 per 100,000, behind fellow high-income region North America (1720). Tropical Latin America (255), the Caribbean (246), and central Latin America (188) showed the lowest age-standardised prevalence.

The global prevalence of gout was calculated at 55.8 million cases in 2020 (including 41.6 million males and 14.1 million females), which represented a 151% change in cases from 1990.

“A big part of it is the fact that we’re getting older,” Professor Day said.

“But even on top of that there’s still an increased prevalence, so it seems like metabolic syndrome and all the things that contribute are really important matters and opportunities.

“It’s a big problem. It’s the commonest inflammatory arthritis in men. It’s something we can really treat well and prevent.

“And it’s a canary in the in the mine for accelerated cardiovascular disease and accelerated renal deterioration. So, there’s lots of impetus to do better.”

The authors of The Lancet article said risk factors such as high BMI should be addressed, with timely access and adherence to treatment to prevent the transition from acute to chronic tophaceous or chronic erosive gout, or both.

“Reducing other risk factors such as alcohol and sugar-sweetened beverage intake and consumption of purine-rich food, not currently quantified in GBD modelling for gout, might also reduce the burden of gout,” they wrote.

Effective management strategies for gout include treatment of the acute flares and ameliorating the long-term consequences that contribute to disability.

Professor Day said treatment and attitudes towards gout had changed drastically in the past 30 years and moved away from the thinking that it was primarily a lifestyle disease. He said better understanding of the disease and better medications to control and prevent flares had also resulted in more people receiving a diagnosis. This would have contributed to the rise in case reports, he said.

And while males remain more commonly diagnosed (the study estimated the global number of males with gout at 41.7 million and 14.1 million females), more women were also being diagnosed.

“The postmenopausal rates catch up fairly quickly for gout in women,” said Professor Day.

“It’s a bit like particular cardiovascular diseases in that the presentations can be a bit different in women. We had a bad history of overlooking presentations, so it’s a good point to make that there is a significant risk of gout in post-menopausal women.”

Professor Day said a more collaborative model of care that included rheumatologists, GPs and specialist nurses, as well as other specialists like cardiologists, endocrinologists and hepatologists would help better manage the disease and related comorbidities.

Treatment adherence also remained one of the biggest challenges and that needed more attention.

He conceded that the biggest burden was likely to fall on primary care, given that rheumatologists usually only saw patients during an acute flare.

“Primary care is under all sorts of stress and tension but that’s really where it ought to happen. Rheumatologists, nephrologists and diabetologists, they can provide help with education leadership programs and stuff like that. But actually, at the end of the day, it’s got to happen out in primary care and community care. But our system is really not up to it at present.”

The Lancet Rheumatology 2024