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18-07-2017 | Gout | Editorial | Article

The future of gout: Are you ready for it?

Fernando Pérez-Ruiz

Gout is, at least if not curable [1], a reversible disease if a ‘treat-to-target’ serum urate approach is implemented [2]. Nevertheless, the trend of gout healthcare seems to be immersed in clinical inertia [3] and passive attitudes [4]. The most recent data, subsequently discussed in more detail, suggest that we are facing a trend toward older patients with more severe disease, who more frequently visit the emergency room (ER), are more frequently hospitalized, stay longer in hospital, and are more frequently readmitted.

Crystal arthritis, including both gout and acute pyrophosphate arthritis, is characterized by intense, abrupt pain and swelling that frequently requires a visit to the ER. In addition to the severity of pain, systemic symptoms such as fever or malaise may also mimic that of septic arthritis; crystal arthritis is also associated with an increased risk of septic arthritis [5, 6]. Therefore, acute crystal arthritis is a common cause of visits to the ER and hospitalization [7].

An analysis of the National Emergency Department Sample data [8] from 2006 to 2008 showed that gout was the primary indication for approximately 0.2% of all visits to the ER annually in the US, generating costs of more than $128 million in 2006 and $166 million in 2008, a 30% increase in 2 years. Further analysis of the same database showed a 14% increase in the rate of ER visits from 2006 to 2012, and an increase in costs of up to $281 million, an 80% increase in 6 years [9]. The mean cost per ER visit in 2012 exceeded $1000, and 7.7% of patients were admitted to hospital, with the highest odds of hospitalization being associated with older age and the presence of comorbid conditions [10].

While from 1993 to 2011 the annual hospitalization rate in the US for patients with a principal discharge diagnosis of rheumatoid arthritis (RA) declined from 13.9 to 4.6 per 100,000 adults (p<0.001), the rate for gout doubled from 4.4 to 8.8 per 100,000 adults, with no difference being observed among age and sex subgroups [11]. The hospitalization rate for gout is now twofold that for RA.

At the hospital level, the impact of gout is not just in the increased rate of hospitalization, but there is also an increased risk of flares during hospitalizations due to other primary causes [12], the adjusted odds of experiencing attacks of gout being fourfold with hospitalization. Of note, less than half of patients were on urate-lowering medications and less than one-third were on colchicine, while the time from the onset of gout averaged 5 years, suggesting a trend for passive therapeutic attitude.

At the recent 2017 European League Against Rheumatism (EULAR) Annual Congress, emphasis was placed on the hospitalization rate due to gout. An analysis of the National Inpatient Sample database, a US national hospital database, found a 400% increase in all-cause hospitalizations in patients with gout (as primary or secondary diagnosis) from 1993 to 2014, averaging a 20% increase per year, whereas the increase in the general population was only 4% [13] – a 100-fold difference, no statistics needed.

This trend was also observed in Sweden [14] from 2009 to 2012 and in Spain [16] from 1991 to 2016, especially in the elderly population, and a 40% increase in the mean duration of hospitalizations was also observed, with both variables influencing the subsequent increase in costs [14]. Once again, between one in four [14] and less than half [16] of patients were on urate-lowering medications prior to hospitalization.

Using the 2013 National Readmission Database, a study found that 11% or 14% of patients were readmitted with gout within the first 30 days following an admission for gout as the primary diagnosis or index diagnosis, respectively [15]. In most cases this was due to complications (eg, heart or kidney failure, sepsis) and associated kidney and heart comorbidities [15]. The impact of nosocomial or joint infection (for sepsis) and the use of non-steroidal anti-inflammatory drugs (for heart and kidney complications) on the rate of readmission were not evaluated but would have been interesting to know.

An increase in the rate of hospitalization, along with an increase in the age and comorbidities (especially chronic kidney disease and cardiovascular events), has been reported in the last quarter of a century [16]. In this cohort, despite the increasing severity observed at referral (regarding the presence of tophi, joint structural damage, and polyarticular joint involvement), less than half of patients were regularly prescribed urate-lowering medications.

All of the above shows that gout is replacing RA as the most common cause of hospitalization among patients with rheumatic or musculoskeletal diseases, due in part to the reduction in the hospitalization rate for RA, but also due to an increase in the rate of hospitalization for gout. Hospitalized patients with gout are now older, more frequently have comorbidities (especially those comorbidities that hinder medical management), and have more severe disease, with increased duration of hospitalizations. For those who are not hospitalized for gout as a primary diagnosis, the risk of flare ups is strikingly increased. Interestingly, in many of the studies discussed above, there was a very low rate of active prescriptions for urate-lowering medications, not taking into consideration that many cases are probably undertreated.

The daunting future for gout is that we persist with clinical inertia and passivity. Are you ready for it?