Insight into Maladies of Major Importance, Racial Disparities & More
SAN DIEGO—During ACR Convergence 2023, a panel discussion, titled Optimizing Clinical Care in Gout, outlined the current best practices for treating gout flares, preventing future flares, lowering urate levels and managing comorbidities. Experts also highlighted persistent, documented racial inequities in gout treatment, disease burden and outcomes of treatment.
Gout & Its Comorbidities
Nicola Dalbeth, MD, professor and head of the Department of Medicine at the University of Auckland, New Zealand, said the treatment paradigm for gout is well known to rheumatologists. That paradigm includes the use of anti-inflammatory agents, such as non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, colchicine, interleukin 1 inhibitors and urate-lowering therapy, such as allopurinol.
The comorbidities accompanying gout, particularly cardiovascular disease (CVD), chronic kidney disease (CKD) and diabetes, also have important consequences for patients—as evidenced by a persistent premature mortality gap. Rheumatologists became even more aware of the comorbidities of gout during the COVID-19 era, Dr. Dalbeth said. People with gout have increased risk of poor outcomes in the setting of COVID-19, much of it related to coexisting cardiometabolic comorbidities.1,2
One unanswered question highlighted by Dr. Dalbeth: Is gout-related hyperuricemia driving poor cardiovascular outcomes (e.g., acute myocardial infarction [MI] and stroke), as was once believed? Mendelian randomized studies and clinical trials, including the All-HEART study in a general population, have indicated that serum urate reduction has no major causal effect on cardiovascular events.3
“Are we actually looking in the wrong place for CVD risk?” she asked. Perhaps gout flare itself and its acute inflammation are contributing to increased cardiovascular risk—with the odds of an acute MI or stroke substantially higher in the first 120 days following a gout flare.
Anti-inflammatory agents used to manage gout also benefit cardiovascular risk in the general population. Colchicine is effective at preventing and treating gout flares when starting urate-lowering therapy. Cardiovascular benefits of low-dose colchicine are also seen in a non-gout population in patients post-MI and those with stable CVD.4 Canakinumab, an anti-inflammatory monoclonal antibody used to treat rheumatic conditions, is also effective for gout flares.
Treatment Strategies
Dr. Dalbeth emphasized the need for a more systematic program for the intensive management and risk reduction of CVD and CKD in patients with gout. That approach includes assessing for vascular risk factors and screening for CKD.
Treatments for these comorbidities that also potentially benefit gout management include: