Gout Prevalence on the Upswing, MDs on the Downswing

The prevalence of gout has been skyrocketing and there are not enough physicians including rheumatologists around to manage the patients.

An estimated 8.3 million American adults are diagnosed with gout, reflecting a 1.2% rise in the prevalence of the disease in the past 2 decades, according to the analyses of national data by researchers at Boston University (Arthritis Rheum. 2011 [doi: 10.1002/art.30520]).

What adds to the burden of this disease are the growing aging population and physician shortage. Studies have shown that there is a shortages of rheumatologists, whose numbers continue to decline as they age out of the system. And some worry that primary care physicians, who are also in short supply and care for more than 90% of gout patients, need more education.

© Vasilis Varsakelis/Fotolia.com

Speaking of the increased gout prevalence, one of the study authors, Dr. Hyon K. Choi, said "To me, it’s substantial. Four percent of the population having gout is not ignorable."

Western diets, sedentary lifestyle, hypertension, the obesity epidemic, and increased use of diuretics and aspirin have been among the culprits for this increase, Dr. Choi and his colleagues reported.

"We're not surprised by the [findings]," said Dr. Christopher M. Burns, a rheumatologist at Dartmouth Medical School, Lebanon, N.H., who was not involved in the study. "The trend has been going on for quite some time now. It's more of a national health issue, because it correlates well with the obesity epidemic."

Studies have suggested that gout is strongly associated with the metabolic syndrome and may lead to myocardial infarction, diabetes, and premature death, the authors noted.

Findings from some studies have shown the incidence of gout is also increasing worldwide. This has occurred despite stepped up prevention efforts: findings from other studies have shown there was an 80% increase in the use of serum urate-lowering or other gout medications during the 1990s (J. Rheumatol. 2004;31:1582-7).

As for the physician shortage, "the relative loss of rheumatologists may make the overall care of gout patients worse unless we do a better job of educating our primary care colleagues about new diagnostic and therapeutic guidelines," said Dr. N. Lawrence Edwards, professor of medicine at the University of Florida, Gainesville.

Previous analyses of national data have documented the steady rise in the prevalence of gout since the 1960s. (Arthritis Rheum. 2008;58:26-35). Researchers suspected a continued rise since the most recent gout estimates from the 1988-1994 National Health and Nutrition Examination Survey III (Am. J. Kidney Dis. 2002;40:37-42).

To estimate the prevalence in the new millennium, they analyzed data from the Centers for Disease Control and Prevention’s 2007-2008 NHANES. They compared data from the 18,825 participants in NHANES III with 5,707 participants in NHANES, all of whom were at least 20 years old. They also analyzed the prevalence of hyperuricemia and the serum urate levels. The average age of participants was 47 years old, made up of 48% men and 69% women.

Results showed that the prevalence of gout, hyperuricemia, and high serum urate levels all significantly increased during the past 2 decades.

The prevalence of gout increased from 2.7% in NHANES III to 3.9% in NHANES (a 44% relative risk increase). The prevalence of hyperuricemia increased by 3.2%, affecting 43.3 million (21.4%) adults. (For more hyperuricemia and serum urate levels, see sidebar.)

Gout prevalence also increased by age, with people aged 20-29 years at 0.4% and those in the population aged 80 years and older at 12.6%. Prevalence among the Medicare population (65 years and older) was 9.8%.

To calculate the impact of risk factors, researcher conducted stepwise adjustments for body mass index and hypertension, which reduced the odds ratio to 1.21, and additional adjustment for diuretic use and alcohol further attenuated the association.

"Most of the [prevalence] increase falls out when you correct for BMI and hypertension," said Dr. Burns. "It's a major health issue in the country. And it’s not just gout, but also hyperuricemia."

The rising prevalence of gout in the elderly population is also of particular concern, said Dr. Choi. The study estimates that 1 in 10 men and 1 in 20 women 60 years and older have gout.

Dr. John W. Rachow, a geriatrician and rheumatologist who works with nursing home patients, said that in his 30-year career, he has seen a steady rise in the number of gout patients. "Morbid obesity in nursing homes is higher than when I started," said Dr. Rachow of the University of Iowa, Iowa City.

Given the rising rates of obesity and hypertension, Dr. Choi and other rheumatologists stressed the importance of taking a holistic approach to treating patients with gout and hyperuricemia, starting with preventive measures.

Dr. Edwards said that "Physicians should all be more aggressive in how we coach patients on weight reduction and other lifestyle modifications including exercise. We should be routinely monitoring serum urates in at-risk patients so that we can review the nonpharmacologic approaches to urate lowering and management of their comorbid diseases."

Dr. Choi and his associates recommend avoidance of heavy drinking, "while moderate drinking, sweet fruits, and seafood intake (particularly oily fish) should be tailored to the individual, considering their anticipated health benefits against cardiovascular disease." They added that coffee and vitamin C supplementation may be long-term preventive measures that can lower urate levels and reduce the risk of gout and associated comorbidities.

There remain unmet challenges.

Dr. Burns noted that "It’s easy to treat people for what they come to you for. The problem is getting people to change their lifestyle," especially for those who have arthritis for whom exercising is not easy.

Meanwhile, the increase in the number of gout patients, majority of whom are cared for by primary care physicians, raises some concerns among rheumatologists.

Dr. Maria Saurez-Almazor noted that the challenge for primary care is the management of more complex patients, particularly with the advent of new therapies with which they may not be familiar," said, head of rheumatology at the University of Texas M.D. Anderson Cancer Center. The solution? "Education, education, education," she said. "For physicians to treat hyperuricemia to target, often this goal is not pursued aggressively. For patients, understanding the role of lifestyle modifications, and the importance of adherence to therapy (non-adherence is very high in this population) is crucial."

The study has some limitations, Dr. Choi and his colleagues reported.

"Unlike estimates of serum urate levels that are based on objective measures, gout prevalence estimates in the NHANES studies are based on self-reports and are thus likely inflated, similar to other condition estimates based on the NHANES. On the other hand, we cannot rule out the possibility that the survey might have missed gout cases that have not been diagnosed by health care professionals," the authors wrote.

Dr. Choi predicted that the prevalence of gout has been rising since the NHANES data was collected. The next step, he said, "is to work on preventive strategies that now have been shown to be effective by multiple studies. So manipulation of these factors should be more aggressively implemented rather than ignored. Improvement in managing these factors can help slow down the escalation."

Dr. Choi has received research funding for other projects from Takeda Pharmaceuticals and has served on advisory boards for Takeda. The study was supported by Takeda Pharmaceuticals International Inc. Other physicians quoted had no relevant disclosures.

The prevalence of gout has been skyrocketing and there are not enough physicians including rheumatologists around to manage the patients.

An estimated 8.3 million American adults are diagnosed with gout, reflecting a 1.2% rise in the prevalence of the disease in the past 2 decades, according to the analyses of national data by researchers at Boston University (Arthritis Rheum. 2011 [doi: 10.1002/art.30520]).

What adds to the burden of this disease are the growing aging population and physician shortage. Studies have shown that there is a shortages of rheumatologists, whose numbers continue to decline as they age out of the system. And some worry that primary care physicians, who are also in short supply and care for more than 90% of gout patients, need more education.

© Vasilis Varsakelis/Fotolia.com

Speaking of the increased gout prevalence, one of the study authors, Dr. Hyon K. Choi, said "To me, it’s substantial. Four percent of the population having gout is not ignorable."

Western diets, sedentary lifestyle, hypertension, the obesity epidemic, and increased use of diuretics and aspirin have been among the culprits for this increase, Dr. Choi and his colleagues reported.

"We're not surprised by the [findings]," said Dr. Christopher M. Burns, a rheumatologist at Dartmouth Medical School, Lebanon, N.H., who was not involved in the study. "The trend has been going on for quite some time now. It's more of a national health issue, because it correlates well with the obesity epidemic."

Studies have suggested that gout is strongly associated with the metabolic syndrome and may lead to myocardial infarction, diabetes, and premature death, the authors noted.

Findings from some studies have shown the incidence of gout is also increasing worldwide. This has occurred despite stepped up prevention efforts: findings from other studies have shown there was an 80% increase in the use of serum urate-lowering or other gout medications during the 1990s (J. Rheumatol. 2004;31:1582-7).

As for the physician shortage, "the relative loss of rheumatologists may make the overall care of gout patients worse unless we do a better job of educating our primary care colleagues about new diagnostic and therapeutic guidelines," said Dr. N. Lawrence Edwards, professor of medicine at the University of Florida, Gainesville.

Previous analyses of national data have documented the steady rise in the prevalence of gout since the 1960s. (Arthritis Rheum. 2008;58:26-35). Researchers suspected a continued rise since the most recent gout estimates from the 1988-1994 National Health and Nutrition Examination Survey III (Am. J. Kidney Dis. 2002;40:37-42).

To estimate the prevalence in the new millennium, they analyzed data from the Centers for Disease Control and Prevention’s 2007-2008 NHANES. They compared data from the 18,825 participants in NHANES III with 5,707 participants in NHANES, all of whom were at least 20 years old. They also analyzed the prevalence of hyperuricemia and the serum urate levels. The average age of participants was 47 years old, made up of 48% men and 69% women.

Results showed that the prevalence of gout, hyperuricemia, and high serum urate levels all significantly increased during the past 2 decades.

The prevalence of gout increased from 2.7% in NHANES III to 3.9% in NHANES (a 44% relative risk increase). The prevalence of hyperuricemia increased by 3.2%, affecting 43.3 million (21.4%) adults. (For more hyperuricemia and serum urate levels, see sidebar.)

Gout prevalence also increased by age, with people aged 20-29 years at 0.4% and those in the population aged 80 years and older at 12.6%. Prevalence among the Medicare population (65 years and older) was 9.8%.

To calculate the impact of risk factors, researcher conducted stepwise adjustments for body mass index and hypertension, which reduced the odds ratio to 1.21, and additional adjustment for diuretic use and alcohol further attenuated the association.

"Most of the [prevalence] increase falls out when you correct for BMI and hypertension," said Dr. Burns. "It's a major health issue in the country. And it’s not just gout, but also hyperuricemia."

The rising prevalence of gout in the elderly population is also of particular concern, said Dr. Choi. The study estimates that 1 in 10 men and 1 in 20 women 60 years and older have gout.

Dr. John W. Rachow, a geriatrician and rheumatologist who works with nursing home patients, said that in his 30-year career, he has seen a steady rise in the number of gout patients. "Morbid obesity in nursing homes is higher than when I started," said Dr. Rachow of the University of Iowa, Iowa City.

Given the rising rates of obesity and hypertension, Dr. Choi and other rheumatologists stressed the importance of taking a holistic approach to treating patients with gout and hyperuricemia, starting with preventive measures.

Dr. Edwards said that "Physicians should all be more aggressive in how we coach patients on weight reduction and other lifestyle modifications including exercise. We should be routinely monitoring serum urates in at-risk patients so that we can review the nonpharmacologic approaches to urate lowering and management of their comorbid diseases."

Dr. Choi and his associates recommend avoidance of heavy drinking, "while moderate drinking, sweet fruits, and seafood intake (particularly oily fish) should be tailored to the individual, considering their anticipated health benefits against cardiovascular disease." They added that coffee and vitamin C supplementation may be long-term preventive measures that can lower urate levels and reduce the risk of gout and associated comorbidities.

There remain unmet challenges.

Dr. Burns noted that "It’s easy to treat people for what they come to you for. The problem is getting people to change their lifestyle," especially for those who have arthritis for whom exercising is not easy.

Meanwhile, the increase in the number of gout patients, majority of whom are cared for by primary care physicians, raises some concerns among rheumatologists.

Dr. Maria Saurez-Almazor noted that the challenge for primary care is the management of more complex patients, particularly with the advent of new therapies with which they may not be familiar," said, head of rheumatology at the University of Texas M.D. Anderson Cancer Center. The solution? "Education, education, education," she said. "For physicians to treat hyperuricemia to target, often this goal is not pursued aggressively. For patients, understanding the role of lifestyle modifications, and the importance of adherence to therapy (non-adherence is very high in this population) is crucial."

The study has some limitations, Dr. Choi and his colleagues reported.

"Unlike estimates of serum urate levels that are based on objective measures, gout prevalence estimates in the NHANES studies are based on self-reports and are thus likely inflated, similar to other condition estimates based on the NHANES. On the other hand, we cannot rule out the possibility that the survey might have missed gout cases that have not been diagnosed by health care professionals," the authors wrote.

Dr. Choi predicted that the prevalence of gout has been rising since the NHANES data was collected. The next step, he said, "is to work on preventive strategies that now have been shown to be effective by multiple studies. So manipulation of these factors should be more aggressively implemented rather than ignored. Improvement in managing these factors can help slow down the escalation."

Dr. Choi has received research funding for other projects from Takeda Pharmaceuticals and has served on advisory boards for Takeda. The study was supported by Takeda Pharmaceuticals International Inc. Other physicians quoted had no relevant disclosures.

The prevalence of gout has been skyrocketing and there are not enough physicians including rheumatologists around to manage the patients.

An estimated 8.3 million American adults are diagnosed with gout, reflecting a 1.2% rise in the prevalence of the disease in the past 2 decades, according to the analyses of national data by researchers at Boston University (Arthritis Rheum. 2011 [doi: 10.1002/art.30520]).

What adds to the burden of this disease are the growing aging population and physician shortage. Studies have shown that there is a shortages of rheumatologists, whose numbers continue to decline as they age out of the system. And some worry that primary care physicians, who are also in short supply and care for more than 90% of gout patients, need more education.

© Vasilis Varsakelis/Fotolia.com

Speaking of the increased gout prevalence, one of the study authors, Dr. Hyon K. Choi, said "To me, it’s substantial. Four percent of the population having gout is not ignorable."

Western diets, sedentary lifestyle, hypertension, the obesity epidemic, and increased use of diuretics and aspirin have been among the culprits for this increase, Dr. Choi and his colleagues reported.

"We're not surprised by the [findings]," said Dr. Christopher M. Burns, a rheumatologist at Dartmouth Medical School, Lebanon, N.H., who was not involved in the study. "The trend has been going on for quite some time now. It's more of a national health issue, because it correlates well with the obesity epidemic."

Studies have suggested that gout is strongly associated with the metabolic syndrome and may lead to myocardial infarction, diabetes, and premature death, the authors noted.

Findings from some studies have shown the incidence of gout is also increasing worldwide. This has occurred despite stepped up prevention efforts: findings from other studies have shown there was an 80% increase in the use of serum urate-lowering or other gout medications during the 1990s (J. Rheumatol. 2004;31:1582-7).

As for the physician shortage, "the relative loss of rheumatologists may make the overall care of gout patients worse unless we do a better job of educating our primary care colleagues about new diagnostic and therapeutic guidelines," said Dr. N. Lawrence Edwards, professor of medicine at the University of Florida, Gainesville.

Previous analyses of national data have documented the steady rise in the prevalence of gout since the 1960s. (Arthritis Rheum. 2008;58:26-35). Researchers suspected a continued rise since the most recent gout estimates from the 1988-1994 National Health and Nutrition Examination Survey III (Am. J. Kidney Dis. 2002;40:37-42).

To estimate the prevalence in the new millennium, they analyzed data from the Centers for Disease Control and Prevention’s 2007-2008 NHANES. They compared data from the 18,825 participants in NHANES III with 5,707 participants in NHANES, all of whom were at least 20 years old. They also analyzed the prevalence of hyperuricemia and the serum urate levels. The average age of participants was 47 years old, made up of 48% men and 69% women.

Results showed that the prevalence of gout, hyperuricemia, and high serum urate levels all significantly increased during the past 2 decades.

The prevalence of gout increased from 2.7% in NHANES III to 3.9% in NHANES (a 44% relative risk increase). The prevalence of hyperuricemia increased by 3.2%, affecting 43.3 million (21.4%) adults. (For more hyperuricemia and serum urate levels, see sidebar.)

Gout prevalence also increased by age, with people aged 20-29 years at 0.4% and those in the population aged 80 years and older at 12.6%. Prevalence among the Medicare population (65 years and older) was 9.8%.

To calculate the impact of risk factors, researcher conducted stepwise adjustments for body mass index and hypertension, which reduced the odds ratio to 1.21, and additional adjustment for diuretic use and alcohol further attenuated the association.

"Most of the [prevalence] increase falls out when you correct for BMI and hypertension," said Dr. Burns. "It's a major health issue in the country. And it’s not just gout, but also hyperuricemia."

The rising prevalence of gout in the elderly population is also of particular concern, said Dr. Choi. The study estimates that 1 in 10 men and 1 in 20 women 60 years and older have gout.

Dr. John W. Rachow, a geriatrician and rheumatologist who works with nursing home patients, said that in his 30-year career, he has seen a steady rise in the number of gout patients. "Morbid obesity in nursing homes is higher than when I started," said Dr. Rachow of the University of Iowa, Iowa City.

Given the rising rates of obesity and hypertension, Dr. Choi and other rheumatologists stressed the importance of taking a holistic approach to treating patients with gout and hyperuricemia, starting with preventive measures.

Dr. Edwards said that "Physicians should all be more aggressive in how we coach patients on weight reduction and other lifestyle modifications including exercise. We should be routinely monitoring serum urates in at-risk patients so that we can review the nonpharmacologic approaches to urate lowering and management of their comorbid diseases."

Dr. Choi and his associates recommend avoidance of heavy drinking, "while moderate drinking, sweet fruits, and seafood intake (particularly oily fish) should be tailored to the individual, considering their anticipated health benefits against cardiovascular disease." They added that coffee and vitamin C supplementation may be long-term preventive measures that can lower urate levels and reduce the risk of gout and associated comorbidities.

There remain unmet challenges.

Dr. Burns noted that "It’s easy to treat people for what they come to you for. The problem is getting people to change their lifestyle," especially for those who have arthritis for whom exercising is not easy.

Meanwhile, the increase in the number of gout patients, majority of whom are cared for by primary care physicians, raises some concerns among rheumatologists.

Dr. Maria Saurez-Almazor noted that the challenge for primary care is the management of more complex patients, particularly with the advent of new therapies with which they may not be familiar," said, head of rheumatology at the University of Texas M.D. Anderson Cancer Center. The solution? "Education, education, education," she said. "For physicians to treat hyperuricemia to target, often this goal is not pursued aggressively. For patients, understanding the role of lifestyle modifications, and the importance of adherence to therapy (non-adherence is very high in this population) is crucial."

The study has some limitations, Dr. Choi and his colleagues reported.

"Unlike estimates of serum urate levels that are based on objective measures, gout prevalence estimates in the NHANES studies are based on self-reports and are thus likely inflated, similar to other condition estimates based on the NHANES. On the other hand, we cannot rule out the possibility that the survey might have missed gout cases that have not been diagnosed by health care professionals," the authors wrote.

Dr. Choi predicted that the prevalence of gout has been rising since the NHANES data was collected. The next step, he said, "is to work on preventive strategies that now have been shown to be effective by multiple studies. So manipulation of these factors should be more aggressively implemented rather than ignored. Improvement in managing these factors can help slow down the escalation."

Dr. Choi has received research funding for other projects from Takeda Pharmaceuticals and has served on advisory boards for Takeda. The study was supported by Takeda Pharmaceuticals International Inc. Other physicians quoted had no relevant disclosures.