A Gout Expert Weighs In
We invited gout expert Robert H. Shmerling, MD, to respond to Dr. Treuhaft’s questions. Click here for his response.
Dear Dr. Helfgott,
As always, I enjoyed your article in The Rheumatologist on gout and hyperuricemia. From reading it, one could assume you have an entire staff devoted only to doing your historical research! The historical detail itself is what prompts this e-mail.
For the past several years or more, the rheumatology literature has often included comments linking this increasing incidence of gout and the epidemic of obesity in the United States. I have little doubt this is true, but another thought has been in my mind as well, and perhaps you can shed some light on it.
At least 15 years ago, the good governmental functionaries who ran Medicare decided that this program shouldn’t pay for services rendered without cause. One of the prominent results was that uric acid levels were eliminated from virtually all automated laboratory analyzers. Since Medicare policy is usually followed by matching policy changes at commercial insurance companies, uric acid testing as a matter of routine screening or health maintenance stopped being done and physicians effectively stopped screening for hyperuricemia, thereby allowing chronic asymptomatic hyperuricemia to go unrecognized and untreated, until that first attack of gout.
So, while increased obesity and the metabolic syndrome play a role, I suspect that our ongoing failure to monitor serum uric acid levels long term has contributed equally—perhaps even more. I haven’t seen this potential linkage alluded to in our literature. Do you know if my hypothesis has ever been considered or proven? Is it logical and can it be tested? If this could be demonstrated to be correct, perhaps it would serve to reinstate uric acid determinations on automated analyzers and insurance coverage to boot.
Thank you and keep up the great work!
William Treuhaft, MD
Rheumatology Division
Legacy Health System
Portland, OR
