Podcast: Play in new window | Download
Gout, the most common form of inflammatory arthritis, can wreak havoc on the body. The good news? It’s easily managed with the right help. Whether you’ve been recently diagnosed, care for someone suffering, or are a medical professional treating the disease, the Kicking Gout in the Acid podcast can help you learn more.
In this episode of Kicking Gout in the Acid, Dr. Larry Edwards is joined by Gout Education Society International Advisory Council member Dr. Puja Khanna, rheumatologist at the University of Michigan. The two discuss the variety of health conditions, also known as comorbidities, commonly seen alongside gout and how they can impact those with the disease.
Key Takeaways:
- Gout is often associated with other metabolic diseases like obesity, kidney disease, heart disease, diabetes, and hyperlipidemia – it’s not simply pain in the toe.
- Gout comorbidities impact the treatment of gout; for example, NSAIDs are not a good option for anti-inflammatory treatment of flares in those with kidney disease or diabetes, prompting the use of different options.
- Those with gout should be on the lookout for symptoms of comorbidities and talk with their doctor to find the best treatment plan for themselves.
- Education is a crucial part of gout management; when combined with self-advocacy, those with gout can reduce the disease’s burden on the body and avoid the negative complications of comorbidities.
Start your journey with gout today via the Gout Education Society website and sign up for the monthly newsletter.
Follow the Gout Education Society on X and Facebook
Looking for nearby gout specialists? Find rheumatologists, nephrologists and more via the Gout Specialists Network.
Educational Materials:
Kicking Gout in the Acid is sponsored by Sobi.
Podcast Transcript
Ian Ponitz
Hello, and welcome to Kicking Gout In The Acid, a podcast from the Gout Education Society. My name is Ian Ponitz, and I’m your host for this series. Kicking Gout In The Acid features conversations between Dr. Larry Edwards, chairman and CEO of the Gout Education Society, and experts on the disease.
Each episode will dive into important topics that you, the listener, should know about gout. The goal? To feel empowered to get gout under control.
In this episode, Dr. Edwards will be joined by Dr. Puja Khanna from the University of Michigan. The two will discuss the role of comorbidities, or related health conditions, alongside gout, how they impact the treatment of gout, and what those with gout can do to mitigate their risk. Dr. Edwards, take it from here.
Dr. Larry Edwards
Thanks, Ian. I’m joined today by Dr. Puja Khanna from the University of Michigan. She is an expert in gout, gout treatment, and is also a member of our advisory council on the Gout Education Society. Puja, maybe you’d like to fill in people a little bit more about your affinity for gout?
Dr. Puja Khanna
Thank you so much, Dr. Edwards. For all purposes, I am a rheumatologist, but my area of expertise has been gout for close to 15, 16 years. I am a trained epidemiologist as well, so my focus has been patient-oriented outcomes. And gout seemed to be a space in rheumatology that had some work going on, but not as much as rheumatoid arthritis, versus more of the orphan diseases, which were scleroderma and lupus. And that’s where I focused in on gout, which was a very common disease known to man for more than 400 years, but we still had very limited treatments, and that’s what prompted me to enter the arena of clinical trials.
I’ve had the fortune of participating as principal investigator in a bunch of trials, including in acute gout and urate-lowering therapies for chronic gout. But where my passion lies is honestly with my patients, and I think there’s a lot of stigma attached to gout, where we need more and more focus and patient advocacy. So, that’s where we are right now in my career trajectory.
For the University of Michigan, my role is to serve as the associate chair of clinical affairs, while I also dabble a little bit in my research area, which is gout.
Dr. Larry Edwards
Good. Terrific. We’ll be working right along those lines of individual care for gout patients because we’re gonna be talking today about the comorbid conditions, the metabolic diseases that are pretty common that occur alongside gout, and talk a little bit about what that interconnection is, and what we think the cause of that relationship is, maybe.
Do you have some thoughts on that?
Dr. Puja Khanna
Absolutely. As we all know, gout is common, but what we have seen is that attention to gout comes forward only when the patient has an acute flare-up in their joints. I think that’s where the travesty lies, because gout happens because of high levels of uric acid, which we define as hyperuricemia.
Hyperuricemia is not just in the joints, as we know. It’s actually a systemic disease. Uric acid can deposit itself across the body, and that is precisely the reason why we see that association of gout with obesity, or gout with kidney disease, gout with heart disease, and gout with diabetes. So, I think that’s where the focus should move, honestly, in my opinion, that we start to think only of the joint and we only treat gout when joints get involved.
But we need to take a step back and think about all of the comorbidities that start earlier than gout, and perhaps we want to bring the focus in on the urate piece and start treating a priori, meaning preemptively, so that we can address the urate burden before it becomes a systemic disease. And there is very little, at that point, that we can reverse, because other organ systems have been involved, and you have developed more comorbidities, and as a result, treatments are difficult.
Dr. Larry Edwards
Yeah. You mentioned a number of the metabolic diseases that gout’s associated with, including obesity, heart disease, and diabetes. I guess hypertension’s probably the most common of those. And taken altogether, along with kidney disease and elevated lipids, I guess all of those taken together is what the medical profession calls metabolic syndrome, which used to be Syndrome X. I always loved that because it has this mysterious ring to it. But metabolic syndrome is very closely associated with, as you say, hyperuricemia and gout.
Are there mechanisms that we can think of that would be true of? You’d said the inflammation outside of the joints, so that there’s more systemic inflammation, maybe. You think that’s a cause?
Dr. Puja Khanna
That is absolutely the cause, because if you want an analogy, it’s similar to elevated blood sugars or high lipid levels. When you have high levels of uric acid circulating in the body, that creates what we call a chronic level of inflammation in the body.
Now, depending on where the uric acid will go and deposit itself, and as we grow older, there is the factor of what we call senescence. As we grow older, every organ system responds differently to the inflammation that is already in the organ system, and then you add another load. So, we’ve noticed in our epidemiologic studies that as we grow older, we have more acute flare-ups. And as a result, the frequency will grow, and you will require things such as steroids for management, or one medication is better in managing the disease, versus the other is more effective, and it becomes harder and harder to treat.
I think there is definitely that element where there is a direct correlation. However, we struggle to show this causal relationship in large observational studies. That is where we want to show proof. And with the various studies that are going on right now, we are slowly and steadily making headway.
Dr. Larry Edwards
Yeah. So I think that the message is that control of gout is both related to control of these other metabolic diseases, and control of the other metabolic diseases is somehow very closely aligned to how easy it would be to get gout under control.
I think for all those people with heart disease and diabetes and hypertension, ignoring their gout is really anti-productive because they’re gonna have a much harder time controlling those conditions.
Now, let’s talk for a little bit about how having these various metabolic conditions, like kidney disease and heart disease and diabetes, affects the kind of medications that we use to treat both the inflammation of gout and the cause of gout, the hyperuricemia. Can you comment on those?
Dr. Puja Khanna
Absolutely. One of the challenges that we have is that with the urate burden, the uric acid in our body is cleared through our kidneys primarily. So, 75% of it is cleared through the kidneys, whereas 25% is going to be cleared through the gut.
And what happens is that if you have kidney disease, maybe because you have hypertension or you have diabetes, or you have heart disease, your kidneys are not functioning well, and the clearance of urate also goes down. That is one of the key things that lowers your ability to process, for the body to process that acute flare-up as well. And that is important to remember because folks who have kidney disease end up veering away from medications such as non-steroidal anti-inflammatories or even medications like Colchicine because we have realized that they can actually cause more adverse effects, for instance, not only on the kidneys, but also on the gut.
So you rely on a class of medications, which is called corticosteroids. Now, the beauty of corticosteroids is that they are very effective, but they’re only effective when you start them promptly as soon as an acute flare starts. There is a large body of data to show similar efficacy with Colchicine and non-steroidals.
But the challenge with corticosteroids is what? That they also have their own side effects. For instance, in a patient who is diabetic, you know that corticosteroids are going to elevate their blood sugar. So you can’t really treat that acute flare for prolonged periods of time because obviously you will see the blood sugars rise up, where they could have more issues. It’s going to, obviously, in the long run, worsen their diabetes as well if they’re having frequent flare-ups and you’re requiring steroids.
Now, with that being said, this is an issue not just for diabetics, but for patients who have heart disease. They may have heart disease, and they can’t use non-steroidals, but if you use steroids in patients with heart disease, what you’re worrying about is, again, the volume. You can retain a lot of fluid, and that can inadvertently worsen their congestive heart failure, which is another comorbidity that we see in our gout patients.
So, I think where I’m leading everybody is that it’s very important to pay attention to all of the different conditions that you have, which we describe as comorbidities, and try to keep them in mind as you are thinking about the different treatments to use in patients who have gout, especially when they have acute flares. But that being said, it’s also important to pay attention when you are looking at chronic treatments for gout, meaning chronic treatments to lower the uric acid.
So I know, Dr. Edwards, you’re gonna go into the various medications that we treat. But one of the medications that we commonly use is Allopurinol. And we also use Probenecid, for instance. Probenecid not so much nowadays, but Allopurinol has been known since the mid-1960s, if I’m not mistaken. And what has happened is that initially it was thought that Allopurinol worsened kidney disease, so we were not optimally using the correct doses of Allopurinol and that has actually hurt our gout patients. Why? Because we know Allopurinol is a very effective drug, but there weren’t that many studies showing that indeed your kidney function did not drop.
So I think there are a lot of medications which are good medications to treat both acute and chronic gout. But we need to bring back the attention on optimal use of medications while keeping in mind the patient’s comorbidity profile.
Dr. Larry Edwards
Just being on a drug doesn’t mean that it’s gonna be an effective therapy for gout. We have a treat-to-target mantra that I think all of us that treat gout patients live by and are recommended by all the major medical professional organizations.
If you’re using a drug like allopurinol and not getting them to the target of a uric acid of less than six, then you could potentially be causing more problems than you’re fixing by having it. So I think your point’s well taken.
Dr. Puja Khanna
Absolutely. And I think what is important is also to pay attention to the fact that as we grow older, our requirements of gout management also need to evolve. You cannot use the same class of drugs at the same doses as the body grows older. You have to tailor it and customize it based on comorbidities.
Dr. Larry Edwards
I think part of that is monitoring and knowing what your uric acid level is, but I think that’s one of the big problems with gout for people with diabetes. Almost all my patients that I see with diabetes know what their hemoglobin A1C was over the past year. Hypertensive patients know what their blood pressures are. Kidney patients know where their creatinine clearance or their glomerular filtration rate is.
But most of my patients when I see them can’t recall what their last uric acid is, and they need to be the shepherds of this whole thing. They need to recognize when their uric acid is at target. And if it’s not at target, they should be the ones knocking on the doctor’s door and demanding better therapy.
Dr. Puja Khanna
Yeah, and you bring up a very good point. I think it’s key that we make the patient their own advocate because historically, what has happened is that gout is treated as only an acute disease, right? When you have a flare, you treat it, you move on. And that was probably the reason why, I’m sure you’ve seen in your practice, there were several patients who were left just on colchicine alone, daily dosing of colchicine, and were not on urate-lowering therapy. Their urates were rampantly high, and they actually ended up having side effects of colchicine, and colchicine, as we know, is not dialyzable.
In my practice, I remember my first patient as a resident was actually given such high doses of colchicine that he wiped out his bone marrow. So that’s where the newer studies have shown us that we can use lower doses of colchicine to treat the acute flare-ups.
But now there is another study that has looked at using low-dose colchicine for cardiovascular prevention in patients who have atherosclerosis. But I think my hesitancy there is that it was shown more from a point of secondary prevention, not primary prevention. Primary prevention is what you were just talking about, urate-lowering therapy to a target.
I think that’s the key message that if we can somehow get across to our patients that, “Be your advocate, start the conversation the first time you have a flare, not when you’ve had a flare over a decade, and you’ve developed O5.”
These are things that we forget because the average primary care physician is dealing with so many medical conditions in a single patient at any given time. And when gout does not happen often, you really don’t bring attention to that particular problem. It’s at the back of your mind, and it gets ignored.
Dr. Larry Edwards
Should the primary care physicians go looking for gout in patients who, say, present with maybe a little bit of obesity and some high blood pressure, and some type 2 diabetes? Are these people that are at risk for gout, and how aggressively should they get at looking for uric acid problems?
Dr. Puja Khanna
I think if you have kidney disease and diabetes already, those two things alone should prompt you to check your uric acid level anyway, because most of us will have one or the other episode of arthritis in our lives anyway. Arthritis is common. But I don’t think we should put the full onus on just having an arthritis flare first. We should start preemptively. From a mindset of prevention is where I would focus when you’re seeing these patients, because otherwise it’s a missed opportunity and the patient develops tophaceous gout.
So yes, checking uric acid, which used to be part of our SMA, if I’m not mistaken, 20 years ago or so, fell sideways, is a good idea because at least you will have an idea of what the urate level is. And that way, you also show the patient objective data where you’re saying, “Okay, you’ve had a couple of flares.” According to our guidelines, we don’t quite start urate-lowering therapy with the first flare, but once we’re seeing a regular cadence of flares, the urate is creeping up, and you’re also showing the patient objective data that this is something that is important.
An analogy is the same as lipids versus an A1C. We define pre-diabetic ranges. So my threshold is if this uric acid was checked for some odd reason, you know, 10 years ago, and that was in the range of like fives. Now it has gone up to a 6.77. That’s what I think needs to be brought to the patient’s attention: “Hey, you know what? You’re having some flare-ups. Your uric acid is also going up.” So that way, you start that educational component with the patient in real time.
This is not something that a primary care physician has to spend too much time on. You can always mention it at least and give the patient some resources to start working on, because that way they feel, “Okay, I am my own advocate and I can do something about this.”
Dr. Larry Edwards
Yeah, the education needs to take place for sure, but I think spreading it out over time is an important aspect. That way, we don’t just give them more information than they can use and then forget about doing it again. I think it’s the persistence on our part of continuing to educate over the years that makes a big difference in that.
Dr. Puja Khanna
Yes, and I think one thing that I would also remind ourselves is that this education doesn’t need to happen just in the PCP’s office. As you add on these comorbidities, you need to keep gout in mind at the cardiologist’s office or at the nephrologist’s office, depending on whether the patient has been referred or not. I think the education piece needs to happen across the board, not just with one area of specialty. That’s where there’s a window of missed opportunity, where we could have a much larger impact on the patient.
And one other thing that I’ve discovered in my practice is that there is this behavioral thing that patients consider, which is the shame associated with alcohol: “I drink alcohol, that’s why I have gout.” No. There are multiple factors that feed into you having gout. So, I think it’s important to focus on not just the negatives but the positive aspects. That if you were to do A, B, and C for your diabetes and hypertension, perhaps if you pay attention to your urine as well, overall your health will be better, right?
So, I think those are the things where we need to reorient our educational messages when we talk to our patients.
Dr. Larry Edwards
We put the emphasis on the positive aspects, that it is a common disease that’s commonly mistreated. But good treatment can make all the difference in the world, essentially curing the person of symptoms of gout over time.
Are there any other aspects of this topic, Puja, that you think we need to discuss?
Dr. Puja Khanna
I think we covered quite a few things. At the end, what I will say is that patients
who have developed one, just even one medical condition like high blood pressure, hypercholesterolemia, or diabetes, need to think about making changes. I think we all collectively as a society need to start taking care of ourselves better, turn on that preventative switch in our brain, and say, “Okay, this is the moment I know I’ve discovered a problem. Let’s try to read up more. Let’s try to start having those conversations with our primary care docs and get to good sources of data.”
I think that’s another thing that really plagues the field of gout, because the sources of data need to be sound. And we need to do a better job not only as clinicians but as patients as well to seek out that data because there’s so much data floating around, and it’s easy to get carried away. And you go down that rabbit hole of reading, “Oh, this happened to that person, and this happened to that person.”
But gout, as you said, is a very treatable disease. It’s the only disease in rheumatology that we can, in effect, fix and put you in remission. It’s time we just stood up for ourselves and took action.
Dr. Larry Edwards
Absolutely. And we might mention that the source of some of this good information about the disease would be on the Gout Education website for us.
Puja, thank you for joining me today. It’s been a pleasure as always, and conversations like this have the power to improve awareness of the disease and also empower our patients to care for themselves better. Thank you for coming.
Dr. Puja Khanna
Thank you for having me.
Dr. Larry Edwards
Ian, back to you.
Ian Ponitz
Thanks both for having this fruitful discussion today that can help those with gout, their caregivers, and medical professionals alike kick gout in the acid. If you have gout or treat gout, you can learn more through the website: gouteducation.org
Stay up to date with our organization by signing up for our monthly newsletter or by following us on X or Facebook @gouteducation.
We’ll be back next month with another episode of Kicking Gout In The Acid. Until then, make sure to like, subscribe, and follow our shows on Apple Podcasts, Spotify, and other major platforms.
Thanks for listening in.
