Comprehensive Care for Gout Patients: Tackling Comorbid Conditions

Announcer:

You’re listening to Living Rheum on ReachMD, and this episode is sponsored by Amgen. Here’s your host, Dr. Charles Turck. 

Dr. Turck: 

This is Living Rheum on ReachMD, and I’m your host, Dr. Charles Turck. Here with me today to share key information on common comorbidities associated with gout is Dr. Michael Toprover. Not only is Dr. Toprover the Associate Director of the Rheumatology Fellowship Program at NYU Langone, but he’s also an Assistant Professor in the Department of Medicine at NYU Grossman School of Medicine. Dr. Toprover, welcome to the program.

Dr. Toprover:

Hi, Dr. Turck. Thank you for having me. It’s a pleasure to be here.

Dr. Turck:

Well, why don’t we start, Dr. Toprover, by doing some level setting for our audience. What do we need to know about gout and its epidemiology?

Dr. Toprover:

Sure. So gout is a very common disease. It is, in fact, the most common cause of inflammatory arthritis in adults in the whole world, and here in the U.S., it affects about 4 percent of the U.S. population. It’s more common in males than females and seems to increase in prevalence as people get older.

Dr. Turck:

Now as I understand it, gout isn’t just painful, but it’s also associated with several comorbidities. So if we take a look at some of the most common ones, would you tell us about the prevalence and impact of cardiovascular disease in patients with gout?

Dr. Toprover:

Of course. So this has been a very hot topic in the field of gout in the last couple of years, and it’s for several reasons, including the fact that, of course, gout is a common occurrence in people with cardiovascular disease; hypertension, coronary artery disease, atherosclerosis, stroke, heart failure, peripheral vascular disease, AFib, and blood clots all seem to be more common in gout patients. And for a variety of reasons, this can lead to a complicated course for those patients and can complicate their lives. There’s been a lot of particular interest in the role of gout in coronary artery disease and the impact that coronary artery disease can have on gout as well as how gout can affect coronary artery disease. There’s been a lot of interest in how medications used for gout can also impact cardiac disease.

One of the more recent ones that’s very interesting right now is colchicine, and colchicine is a common medicine that’s used in gout to prevent flareups, and it now seems to be very useful in preventing myocardial infarction in people at high risk. In terms of each one of these, there’s a variety of incidence factors; for example, about 75 percent of gout patients have hypertension, and these values are also pretty high for atherosclerosis, heart failure, and coronary artery disease and higher than the general population.

Dr. Turck:

And what about diabetes? How common is that in patients with gout, and what’s its impact?

Dr. Toprover:

That’s a great question. So diabetes is also more common in patients with gout, with a prevalence of about 16 to 20 percent of gout patients compared to 11 percent in the general U.S. population. And there seems to be a lot of interest in the relationship there, and a lot of it may go back to metabolic syndrome, which of course can lead to both insulin resistance and diabetes, but also to hyperuricemia which is the prerequisite for the development of gout.

Dr. Turck:

Now given the prevalence of these and other common comorbidities, how can they affect a patient’s risk of death?

Dr. Toprover:

I think a very important point here is that people with gout are more at risk of dying of a variety of the comorbidities mentioned before, including heart disease, diabetes, and kidney disease compared to their age-matched population, and so gout seems to increase this risk. It’s unclear why that is. It may be from the inflammation associated with gout. It may be because patients who are hospitalized for a variety of other reasons usually develop gout while in the hospital, which can complicate their stay. There’s definitely a lot of research into how gout affects coronary artery disease. There’s a very interesting paper from Dr. Cipolletta and colleagues out of the U.K. a few years ago that showed that having a gout flare greatly increases the risk of myocardial infarction and stroke in the following 3 months, even once the symptoms of the flare appear to have resolved. And, in fact, hyperuricemia on its own increases the risk of myocardial infarction and death, whereas gout further increases that risk above the general risk about threefold.

Dr. Turck:

For those just tuning in, you’re listening to Living Rheum on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Michael Toprover about uncontrolled gout and its comorbidities.

So, Dr. Toprover, now that we know about some of the most common comorbidities associated with gout, what challenges do these present when managing patients?

Dr. Toprover:

This is a very important point that we as rheumatologists often deal with because many of our gout patients come in with a variety of other comorbidities, including kidney disease, heart disease, diabetes, high blood pressure, and high cholesterol levels. There are several issues here. One is the risk that some of the medications to treat the comorbidities can impact the risk of gout. For example, diuretics, which can often be used in high blood pressure in heart disease and in kidney disease, many of them cause an increase in uric acid and can increase the risk of gout. Additionally, low-dose aspirin can increase uric acid and increase the risk of gout. There are often interactions between some of the medicines for the comorbidities and gout medications. For example, cholesterol medications like statins often have a risk of interacting with colchicine, which is commonly used to prevent flareups in gout. Of course, the level of severity of kidney disease can affect the dosing of gout medications and can heighten the risk of a variety of the medication interactions. And on top of all of that, of course, treating gout often requires several lifelong medications, and patients with comorbidities often already have a very high pill burden and this can further increase it, increasing the risk of noncompliance and adverse effects to the medication.

Dr. Turck:

And before we close, Dr. Toprover, would you share some best practices for overcoming those challenges and proactively managing patients with gout and related comorbidities?

Dr. Toprover:

Of course. I think that this has to do with a multimodal approach. It’s important for patients to understand after speaking with their doctors what their risks of various comorbidities are, understanding how the gout medications work, how they can interact with their other medical problems, and approaching each sort of comorbidity as a part of the whole to make sure that they know exactly what might get better, what might get worse, and what to watch out for. I think it’s definitely a good idea for them to discuss with a rheumatologist, at least for one consultation, if possible, so that they can understand the long-term approach to their gout treatment and how they can, both from a lifestyle and a medication management standpoint, treat their gout the best.

Dr. Turck:

As those best practices bring us to the end of today’s program, I want to thank my guest, Dr. Michael Toprover, for joining me to discuss uncontrolled gout and its associated comorbidities. Dr. Toprover, it was great having you on the program.

Dr. Toprover:

It was great to be here. Thank you.

Announcer:

This episode of Living Rheum was sponsored by Amgen. To access this and other episodes in our series, visit Living Rheum on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!