Gout is the most common arthritis of patients over 40 years of age. Many phycians treat these gouty attacks but do not realize that they should also care for the underlying urate accumulation. It is not only realization but partly also due to the great gout bagatelle: gout has been cartoonized for years as a disease for kings, a disorder for overindulgence, possibly even a punishment for the rich. These assumptions are not helping suffering patients nor treating physicians nor the scientific understanding, nor pharmaceuticals developing new (improved) drugs.

Biological background

Mankind has developed kidneys early in Myocene, that try to keep in the high-energy molecule that urate is. But in current welfaring societies many calories and fructose enriched drinks are used. Many urate molecules are formed and often less is excreted via the kidneys than is actually made. This results in a positive urate balance. The body then has to store these high-energy urate molecules and often the colder feet and slightly arthrotic joints are typical storage compartments.

Attacks

For the treatment of attacks one often prescribes either 1) non-steroidal antiinflammatory drugs, unless kidney function is diminished; or 2) glucocorticoids, unless glucose elevation is feared for; or 3) colchicine, unless not tolerated. Currently in severe cases the more expensive interleukin 1-blockers are to be considered as well.

Urate accumulation

The next phase to be dealt with is the urate lowering drugs, particularly after having had 1 (or more) previous attack(s). However in many cases the window of opportunity to start this urate lowering drugs is not found. Important barriers are that patients may doubt effectiveness of therapy, that patients fear costs, that patients forget to take pills possibly due to life style or traveling etc.

Urate lowering drugs

Since 1952 Probenecid has been marketed, originally for its’ Penicillin-sparing activity, but currently it is an elegant uricosuric for the USA. Since 1964 availalability was reached for the urate production inhibitor Allopurinol, which still is often underdosed worldwide in over 50% of patients. In some countries Benzbromarone, a potent uricosuric was marketed from 1977, but also taken off the market for severe hepatotoxicity in incidental cases. It was later on remarketed for patients who were intolerant for allopurinol, to at least have some rescue medication. Luckily in 2002 Febuxostat was approved which finally gave us the availability of a second choice urate production inhibitor; second choice because of its price. In possibly in 2016 a new uricosuric is made available.

Currently we have to start taking gout seriously, start to treat patients properly to a certain target defined by the rheumatologic communities, and to help newer, possibly improved drugs to the growing market of our gout patients. We will see more gout patients, as this coincides with the increase of obesity, the aging of a population (with diminished renal function), the coexistence of comorbidty and polypharmacy. We will be able to better diagnose gout, and we will have to help the public domain to the correct picture of untreated gout: Fig 1 and Fig 2.

Tim L Th A Jansen, MD, PhD

Rheumatologist/Medical Manager
Dept Rheumatology
VieCuri  Medisch Centrum
Netherland

Publication

Gout: cartoonized and bagatellized and still left untreated. Time to change.
Jansen TL
Clin Rheumatol. 2015 Jul