The Need to Manage Gout Alongside Comorbidities
When managing gout, it’s critical to carefully consider comorbidities to prevent exacerbating one condition while treating the other, or introducing new problems due to drug interactions. Patients and medical professionals can turn to examples from clinical practice, expert research, and academic understanding to navigate the complexities of gout and its associated conditions. For example, patients vividly describe the severe impact of gout flares. One of my patients once likened the pain to being shot, underscoring the intense agony gout can cause. Patient experiences like this underscore the need for effective management strategies. As medical professionals, our goal is to provide comprehensive care that not only manages gout but also improves the patient’s overall quality of life, considering all comorbidities.
The exploration into gout and comorbid conditions aims to help medical professionals recognize and understand how to better tailor management strategies to address the complex health needs of their patients.
Gout and Heart Conditions
When discussing cardiovascular disease and gout, it’s important to consider hypertension and heart-related medications. Some antihypertensive agents can cause a rise in urate levels; considering the relationship between treatments for both diseases will help create a beneficial patient treatment plan. In the American College of Rheumatology (ACR) Gout Guidelines, there is a conditional recommendation that considers switching hydrochlorothiazide to an alternate agent that does not have that negative urate impact. It should be noted that appropriate dosing of urate-lowering therapy should sufficiently overcome any urate increase from such medications. Given the importance of management of hypertension, I aim to optimize urate-lowering therapy before I speak to the physician managing a patient’s hypertension about switching to a different anti-hypertensive medication if I am still having difficulty managing a patient’s gout. Working together with primary-care physicians and/or cardiologists who are managing a patient’s hypertension, the care team may consider the use of an alternate antihypertensive agent such as losartan if high urate levels persist despite optimizing urate-lowering therapy.
Gout Medications Improving Heart Health
Recent cardiovascular trials have provided new insights into the relationship between gout medications and heart health. For example, colchicine has demonstrated benefits for cardiovascular disease in some trials. Fellow Gout Education Society member, Ted Mikuls, MD, MSPH, recently covered the LoDoCo2 and CANTOS trials in another blog post. One consideration regarding long-term use of colchicine for secondary prevention of cardiovascular risk among people with gout is that often statins are prescribed for cardiovascular disease, which can interact with colchicine particularly in those with renal impairment. Thus, long-term strategies being considered for both gout and cardiovascular disease management need to take into account potential drug interactions or other risks.
Cardiovascular Drugs That Can Impact Serum Urate
Management of cardiovascular disease may involve medications that can increase urate levels. Preventative medicine for individuals with coronary artery disease typically involves low-dose aspirin, which can increase serum urate levels. Low-dose aspirin is an important component of managing heart disease in people with existing coronary artery disease but should not but used for primary prevention of heart disease. Thus, when reviewing with a patient on low-dose aspirin, rheumatologists must understand why their patients are on low-dose aspirin. For those on low-dose aspirin for secondary prevention, the medication should be continued, and the physician should attempt to optimize urate-lowering therapy doses regardless of any increase in urate that low-dose aspirin has entailed. On the other hand, if a patient is using low-dose aspirin for primary prevention only, then a discussion should be had regarding appropriateness of its use. It is important to control a patient’s gout flares because elevated urate levels can lead to frequent gout flares, which in turn may increase the risk of heart attacks.
Gout and Renal Conditions
Patients with chronic kidney disease (CKD) face unique challenges in managing gout. There is unwarranted concern among medical professionals about the use of allopurinol in the context of CKD. There is little evidence to support that allopurinol negatively impacts renal function. Discontinuing allopurinol in patients solely based on a rise in creatinine levels can lead to gout flares and does not address the true underlying reason for a patient’s underlying worsened renal function. Proper use of low starting doses with monitoring during dose titration can enable safe management of gout in these patients. Physicians should start patients with CKD on a lower initial dose of allopurinol (e.g., 50mg/d for those with CKD 4 or worse) to mitigate risks of allopurinol hypersensitivity. The choice of urate-lowering therapy to use is impacted by presence of CKD since uricosurics should not be used when renal function is too impaired for uricosuric drugs like probenecid to work.
Gout Flares and Renal Function
Considering renal function is also crucial in safely managing gout flares. Treatment strategies should focus on selecting medications that do not negatively impact kidney function. If an individual has renal insufficiency, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) should not be used because of possible negative impact on renal function. Instead, alternative options should be considered that can be safely used in renal impairment, taking into account the patient’s potential drug interactions and contraindications. For example, one should adjust the dose of colchicine in the setting of renal insufficiency, and be mindful to avoid using colchicine to treat a flare if an individual with renal insufficiency is already on colchicine for prophylaxis. Additionally, close monitoring should be considered if the patient is also on a statin. IL-1 inhibitors can be used, though every-other-day dosing for anakinra should be considered; no dose adjustments for canakinumab are recommended, though its safety has not been studied extensively in people with renal insufficiency.
Gout and Diabetes
Patients with gout often have concomitant diabetes. Patients with diabetes are familiar with treating their hemoglobin A1C to a particular target. Similarly, patients with gout, regardless of presence of other comorbidities, also need to lower their serum urate to a target of <6mg/dL. Gout flares in people with diabetes can be challenging to manage because prednisone can increase blood glucose levels, making diabetes management more challenging, and one would prefer to avoid NSAIDs since people with diabetes and gout often also have CKD. On the other hand, when it comes to managing hyperuricemia, certain diabetes medications, like SGLT2 inhibitors, can also aid in lowering urate levels, offering a promising treatment approach to simultaneously manage both diseases. Collaboration between healthcare providers is essential to optimize treatment plans that effectively address both gout and diabetes. A multidisciplinary approach and integrated care model ensure both conditions are managed without compromising the treatment of either.
A Holistic Approach to Managing Comorbidities
The intersection of gout with other health conditions requires a holistic treatment approach. Through comprehensive care that considers all comorbidities, relevant drug effects and drug interactions, healthcare providers can significantly improve patient outcomes. Still, understanding the nuances of these medications, including dosing considerations and potential side effects, is crucial for making informed treatment decisions and managing multiple diagnoses in patients.
