Case numbers are tipped to explode around the world in the coming decades.
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.
“Some people criticise Global Burden Disease a bit because there aren’t enough numbers to be sort of absolutely sure, but I think it’s good enough,” he said.
“It’s not meant to be absolute; it’s meant to be fairly predictive of what to expect. I think it’s very valuable, but 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.
“So, 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 the second highest in the world (1423 per 100,000) behind fellow high-income region North America (1720 per 100,000). By contrast, Tropical Latin America (255 per 100,000), the Caribbean (246 per 100,000) and central Latin America (188 per 100,000) 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.
The global age standardised prevalence rate (per 100,000) was 659 – an increase of 23% from 1990. In Australasia the prevalence of gout was put at 669,000 people, an increase of 169% from 1990. Australasia’s age-standardised prevalence rate of 1423 per 100,000 was more than double the global average.
Professor Day said the rise in cases over the past 30 years and the prediction that this will continue over the coming decades was also not completely surprising.
“A big part of it is the fact that we’re getting older,” he told Rheumatology Republic.
“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, really, with gout.
“It’s a big problem. It’s the commonest inflammatory arthritis in men. It’s actually something we can really treat well and prevent, pretty much.
“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 actually 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 the most commonly diagnosed of the genders, (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.
“Women have always lived longer than men, but still, everyone’s getting older. And, of course, the postmenopausal rates catch up fairly quickly for gout in women,” said Professor Day.
“And as the comorbidities become more prevalent in women, that trend is increasing. I think again, it’s a bit like particular cardiovascular diseases, 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, primary care health professionals such as 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.
“Having a multidisciplinary approach is a start, but more is needed for sure, and there have been very good studies that show what works,” he said.
“I think it’s a matter of actually how to approach it in a way that can be sustained.”
He conceded that the biggest burden was likely to fall on primary care, given that rheumatologists usually only saw patients during an acute flare.
“It’s not just gout, but all the other things, type 2 diabetes, obesity, hypertension, chronic kidney disease, all of that,” he said.
“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.”
