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Welcome to season two of Kicking Gout in the Acid. This season will dive into additional topics of importance to not only those with gout, but for those treating the disease as well. 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.
This episode of Kicking Gout in the Acid features a conversation between Dr. Larry Edwards and Dr. Robert Keenan, Rheumatologist, Chief Medical Officer at Arthrosi Therapeutics, and member of the International Advisory Council for the Gout Education Society. The two explore the broad reach of gout across different demographics, discuss how gout presents differently, and considerations healthcare professionals should be aware of during treatment.
Key Takeaways:
- Gout doesn’t discriminate by age, gender, background, or diet. Doctors should be aware that the signs of gout aren’t always as straightforward. Misdiagnosis is common, so it’s important to take a step back and recognize the subtle symptoms.
- Genetics play a meaningful, but complex, role. Family history is a significant risk factor, however, research points to polygenic and epigenetic factors than one single genetic mutation.
- Demographics matter, but not in the way most people think. While men typically develop gout in their 40s-50s, the prevalence is nearly equal in women post-menopause.
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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 is joined by Dr. Robert Keenan, Chief Medical Officer at Arthrosi Therapeutics, and member of the Gout Education Society’s International Advisory Council. Today, Dr. Keenan and Dr. Edwards will discuss how gout affects different populations, the role of genetics and gender on gout, and how medical professionals can better serve diverse communities.
Dr. Edwards, take it from here.
Dr. Larry Edwards
Thanks, Ian. I’m happy to be joined today by Dr. Robert Keenan, internationally recognized expert in the field of gout. He’s also the Chief Medical Officer of Arthrosi Therapeutics, and I’m delighted to have us join in our conversation.
Can you start off, Rob, by telling a little bit about what your interest in gout has been over the years and what kind of studies and research you’ve done?
Dr. Robert Keenan
Yeah. Thanks for having me. I appreciate the opportunity to talk about my favorite medical topic or my favorite topic, probably in general, much to my wife’s dismay, of gout.
Yeah, so I got interested in gout back in medical school, quite honestly, and then my interest further developed in residency, then subsequently in fellowship. I had the opportunity at NYU to start a gout registry with the VA there, and that kind of really kicked off my clinical research interest.
From there, I just continued it on as I transitioned to Duke University, and I started a gout clinic and kept up with the clinical research there as a principal investigator for a number of drug studies, as well as principal investigator for some epidemiological studies that were externally funded. So that’s kind of how I kept the love of gout and the love of treatment of gout and taking care of this patient population over the last twenty-plus years now.
Dr. Larry Edwards
Yeah, it’s an incredibly interesting disease with a crazy history to it. It certainly is a fun thing to study, and the nice thing is that it’s essentially a curable disease if patients listen to the recommendations. We have good medications. We’re getting better medications coming down the pipeline, so I think that there’s a lot of hope for the future.
Let’s go ahead, Rob, and start off the discussion today, talking really about the demographics of gout, who gets gout. It’s said that there’s about 9 to 12 million adults in the United States that have gout, coming to about 4% of the population of adults.
What else can you tell us about the demographics of this disease?
Dr. Robert Keenan
Yeah. So I like to tell patients that gout doesn’t discriminate.
I mean, there’s a lot of misnomer about. Oh, it’s the over-indulgent rich person who eats too much, you know, meat and drinks too much alcohol, that gets you gout.
But really, I mean, just pretty much gout can affect any ethnicity, any race across the spectrum. Of course, men are more likely to get gout earlier on, so you think about the typical gout patient as a man in his fifties, you know, late forties, early fifties when they first initially present with their first flare.
But eventually, women do catch up with men post-menopausal. So once they reach menopause, the incidence and prevalence of gout in women starts to catch up with that of men. So by the time they’re seventy-five, eighty, it’s pretty much almost equal to that of men. Again, it can affect anybody.
Now, typically, as far as who gets gout the most, so to speak, there was a recent study that was put out by Yokosi a couple of years ago. I guess it was twenty twenty-three years ago that showed that over the last couple of decades, the Asian population in the US, actually, their prevalence doubled from about 3.3% to about 6.6%. That was a higher increase and a higher rate of increase in prevalence compared to every other ethnic group, including whites and blacks and Hispanics. So I thought that was interesting.
If you look at the black population in general, their prevalence of gout is also higher than that of whites. And you can think, “Well, maybe this is something genetic,” and it’s probably not genetics, especially when people develop gout in their fifties and sixties.
You know, you’ve got to think about a genetic component when they’re developing gout in their late teens or twenties, for example. But it’s not so much genes as it is just potentially lifestyle, other comorbid illnesses like chronic kidney disease or metabolic syndrome.
If you look at that Yokosi study of the Asian population being doubled, you know, it wasn’t double. It was actually lower than whites about thirty years ago. So, as with blacks, it could be just a lack of access to care. It could be not being started on urate-lowering therapy when they should. So that kind of pretty much dictates, and if they develop gout and have not started on anything to bring their uric acid down, then they’re more likely to have gout longer, more flares, and more severe gout down the road.
Dr. Larry Edwards
There’s been a lot of work on the genetics of it, and we can talk about that in a short while.
I think other components you’ve mentioned are the gender, of course, with men predominant early on in the forties, fifties, and sixties, and women becoming much more susceptible to gout as they get into their seventies and eighties. The frequency of gout in that older population, seventy-five, eighty, is actually very high, 20%, 25% percent of the population of adults.
Can you talk a little bit about age?
You mentioned earlier on, Rob, that the image that most people have of gout is some portly old white guy sitting around drinking some alcoholic beverage or eating a large meal. We know that that’s not the primary source of problems. Can you talk about the type of people that you see that would really say that that’s not the problem, as far as women, as far as athletes getting it, people that don’t drink, people that don’t eat meat? All of those are in the spectrum.
Dr. Robert Keenan
Yeah, exactly. So that’s where potentially some of those genes kind of come into play in that patient population, especially whether it’s women, and just post-menopausal, and especially if they have a strong family history, their father had gout, their grandfather had gout, their brothers have gout, there’s a good chance they’ll develop gout.
A lot of times, in women, they’ll present different than men. They won’t necessarily present with a big, hot, painful red big toe. They’ll present with it in their hands, for example, and it might not even flare like a typical gout flare. It might be a little more subtle. And I think that’s important for women to recognize because, you know, I’ve had patients, women patients who came to me for joint pain in their hands, and, you know, they obviously had some osteoarthritis in their hands, and they came to me saying their pain’s just getting worse, and they’re having episodes where it’s just worse some days than others.
Sure enough, I say, “Well, this looks like it could be potentially gout.” And, you know, one patient I can think of off the top of my head said, “I don’t have gout. My husband has gout, but I don’t have gout. There’s no way I have gout. He eats too much,” et cetera, et cetera.
I said, “Well, I think you may have gout. Let’s take some X-rays and see what we see, and then check uric acid and see what we see.” And sure enough, she had gout on top of her osteoarthritis in her hands.
So that patient population certainly is not gonna be necessarily typical in many ways, not only, you know, necessarily what they’re eating or not eating, it’s also the loss of estrogen, therefore the loss of that uricosuric effect from the kidney, and then subsequently maybe a little bit of renal decline in the process that comes along with aging, and the two put together, plus some genetics to go along with it may result in hyperuricemia and subsequently crystal deposition and gout.
Dr. Larry Edwards
So the researchers around the world that are looking at the underlying genetics recognize that there probably are some genetic factors in there, not necessarily the uric acid transporters, like we think most of the problems are. But for instance, obesity itself might have an epigenetic force on these gene mutations that occur in a lot of people.
I think it’s important to point out to patients that there is a significant genetic component to this disease. They suffer from bias and misunderstanding in the community, like your patient thinking that she doesn’t have gout because she’s the female of the couple. But they need to understand that you can be young and healthy and thin and get gout. You can be a mother of three and get gout, and you have to look out for these atypical presentations like you’re describing, not the great big flaming toe that even the second-year medical student would recognize, but something more resembling osteoarthritis or rheumatoid arthritis and being treated differently than they should be for that.
One of my very first gout patients as a rheumatology fellow at the University of Michigan was a poor old guy that had been treated for nearly twenty-five years with medications for, quote, rheumatoid arthritis. And in truth, what he had was just about every joint in his body afflicted by gout, so it’s a different thing.
What else would you say about ethnicity that we haven’t touched on?
Dr. Robert Keenan
Yeah, I’ve been thinking about the epigenetics and polygenic etiologies of gout. I guess geneticists out there, the Tony Merrimans and everybody looking at this, they’ve got their work cut out for them because it might not just be as simple and black and white as one mutation and one gene with a URAT1 transporter, for example, that’s causing an issue.
It might be multiple factors, to your point, that also go along with obesity and other comorbid conditions that always seem to be associated, or a lot of times come along, with gout or vice versa. I mean, there’s specific genetics like SCL2A9 and ABCG2 where those transporters may have some mutations that obviously impact the uric acid levels and subsequently gout.
But it’s those patients that present, you mentioned the mother of three, those are the patients who, unfortunately, sometimes again get misdiagnosed. Or your patient from the University of Michigan, they get misdiagnosed and for months or even years, unfortunately. So when thinking about an inflammatory arthropathy, even though gout’s still the most common inflammatory arthropathy in the United States and the Western world in general, it should come to every provider’s mind, even though it might be atypical.
You can’t immediately jump to RA. You can’t immediately jump to a seronegative. You should always think about gout in that differential diagnosis for this patient population, or for just any time a patient presents with a story of inflammatory joint pain.
Dr. Larry Edwards
Yeah, absolutely right about how it’s actually much more prevalent, maybe four times more prevalent than, say, rheumatoid arthritis, which we see all over the TV, or psoriatic arthritis. It is very, very common and should be in most differential diagnoses of inflammatory arthritis.
Let’s talk just a little bit about how an understanding of these underpinnings of who gets gout can help. We talk about the differences in gender and age groups, and understanding these various demographic components. How does that help us if we’re trying to formulate a therapeutic plan for a patient?
Is it helpful to know that there’s a genetic component to the disease? Is it helpful to know that these other comorbidities, like kidney disease and heart disease and obesity, play a certain role? Does that help us come to a treatment plan that’s focused for this particular patient?
Dr. Robert Keenan
Yeah, I mean, I think it does.
Diagnosing this patient population, again, you gotta think outside the typical forty to fifty to sixty-year-old male who may or may not be overweight and drink or eat too much, because the prevalence of gout increases around 10% to 12%, 13% even with each decade of life.
And by the time they’re eighty years old, especially women, there’s a good chance that if they’re presenting like this or with joint pain in general, it can’t be chalked up to just general osteoarthritis. It could very well be gout. And to think about how to treat this patient population, we’ve got to also treat any comorbid conditions they have, whether it’s hypertension, diabetes, insulin sensitivity, insulin resistance.
You’ve also got to make sure they’re not eating anything, especially before treatment or when you’re just starting uric-lowering therapy, to quote-unquote trigger their gout, high purine content foods, a lot of alcohol, et cetera. But those are the things that need to be addressed in addition to the uric acid levels themselves.
I think if you can kind of kill two birds with one stone and put them on a therapy, it might, you know, whether it’s an ARB that might help their hypertension, also help their uric acid levels a little bit. That’s always better, especially if you want to try to avoid polypharmacy, which a lot of elderly unfortunately have going on these days when it comes to seeing their primary care doctor. They’re put on a statin or a couple of hypertensive drugs, and if they have diabetes, then of course they’re on some anti-diabetic medication. So, I mean, you’ve got to try to overlap as much as you can, minimize diuretics if you can, et cetera.
Dr. Larry Edwards
With the whole target being to get the uric acid level down to a low level.
Dr. Robert Keenan
Exactly, yeah, below six. And you know, I always side with the Brits, and I say this all the time, but I like people less than five, personally. I like that wiggle room. So if they do have too much shrimp or have a few too many beers, you’ve got some wiggle room.
Dr. Larry Edwards
Yeah, you’ll actually eliminate the flares caused by those things if you jump on top of the disease.
You ran a gout clinic there in the Carolinas, like we did down in Gainesville, and I think that when you explain things to patients over and over again with visits, that they become much more adherent to the therapies that we prescribe. And you’re able to, with the basic medications, the xanthine oxidase inhibitors like allopurinol and febuxostat, and uricosuric drugs like probenecid, you can get them down to, like you say, close to five.
As a matter of fact, most of the patients in our clinic were between four and five and did tremendously well. You know, they found the logic appealing of keeping their uric acid low, so they’re not being bumped into clinical flares all the time.
Dr. Robert Keenan
Exactly. And they appreciate that. And they see the results. When people see results, they’re going to listen. I mean, it drives me a little nuts when people talk about how non-compliant gout patients are. But they’re non-compliant because people don’t explain that, you know, when you start even on prophylaxis, prevent flares when you start uric-lowering therapy, and that the uric-lowering therapy will or could potentially cause a flare paradoxically, you know, in most people’s minds.
As you lower the uric acid, you’re more likely to kind of stir things up, if you will, as those solid crystals come back out in the soluble state. I think once they understand that, and you kind of get that across to them, which a lot of times, unfortunately, they’ve never been told that before, they’re more likely to be compliant, and you just kind of tell them, “Okay, it’s a backhanded way to say the drug’s working. It’s doing what it’s supposed to do. We’ll get you through these flares over the next few months, and then after that, you should be most likely 99.99% flare-free.”
So that’s what I try to convey to patients, that this is curable. This is a curable disease, as you mentioned at the beginning. And I think once they realize that and they see a difference, they’re the most compliant people you can find with their therapy.
Dr. Larry Edwards
Yeah. They like to be pain-free.
Dr. Robert Keenan
Exactly.
Dr. Larry Edwards
Good. Good. Thanks so much for this conversation today, Rob. It’s been fun talking to you and fun hearing your take on all of this.
Are there any topics that we haven’t covered that you think are important along this line of who gets gout and how that might help us treat them?
Dr. Robert Keenan
Yeah, no, I just think it’s important to reiterate that you’ve got to think outside the box a little bit and not just think it’s always the middle-aged, overweight male that gets gout. I’ve seen patients as young as fourteen years old. I’ve seen, like you said, athletes, active people with no other comorbidities in their late twenties, get gout. So, I mean, it’s something that we’ve got to keep in mind when it comes to any type of inflammatory arthropathy, especially if it’s intermittent and relapsing, quote-unquote.
It’s important to think about how anybody can develop gout, whether there’s a genetic component or it’s their fault, if you will, with comorbidities, et cetera. But it’s never really their fault. Nobody wants this.
I always tell patients a lot of times, too, just one more thing, that when they ask me if they can lose weight or if they change their diets or whatever, if they’ll lower the uric acid enough. I’m like, “Well, if you can get back down to your high school weight,” and, you know, telling a fifty-five or sixty-year-old this, I say, “There’s a good chance you’ll drop it a couple of points, point and a half, maybe two points.” But even then, if they’re sitting at nine or nine and a half or eight and a half, it might still not be enough, but they’re like, “Okay, well, never mind. Give me whatever you got,” because nobody thinks they can get back down to their high school weight.
So it’s a matter of just making sure that people recognize that it can hit any demographic, basically, and it’s, again, the most common inflammatory arthropathy in the Western world, so it’s just something to keep in mind.
Dr. Larry Edwards
Thank you for those comments, Rob.
It’s terrific, like I said, talking to you, and we do these little podcasts just to kind of help displace some of the misinformation that’s out there about the disease, and I think we did some of that today. Thanks again.
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
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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.
