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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. Jasvinder Singh, rheumatologist at Baylor College of Medicine. The two discuss the socioeconomic impact of gout and barriers to proper treatment to showcase how the disease affects more than just the body.
Key Takeaways:
- Gout comes with a variety of indirect costs (work absenteeism and loss of productivity) and direct costs (doctor visits, medications, and lab tests) that are often unseen by those with the disease.
- Early and ongoing management of the disease is vital to reducing the economic burden on patients.
- A lack of rheumatologists in the United States puts additional pressure on primary care physicians to manage the disease early; however, delayed referrals to rheumatologists can negatively impact patient outcomes.
- While new, there is potential for new therapies and management strategies. The current priority for gout management lies in addressing adherence issues for patients and knowledge gaps for medical professionals.
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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. Jasvinder Singh, rheumatologist from Baylor College of Medicine, to look at the socioeconomic impact of gout, barriers to treatment, and the importance of educating both those with the disease and those involved with its treatment. Dr. Edwards, take it from here.
Dr. Larry Edwards
Thanks, Ian. Now, I’m joined today by Gout Education Society international advisory council member Dr. Jasvinder Singh. Jas, would you be able to tell the listeners just what your interest in gout has been over the years and what your current role is with Baylor University in Houston?
Dr. Jasvinder Singh
Thanks, Larry, for the invitation, and thanks to the Gout Education Society for having this conversation. I am a rheumatologist here at Baylor College of Medicine and a staff physician at the Michael E. DeBakey VA Medical Center. I’ve been interested in gout as a condition since the beginning of my career as a rheumatologist.
I got drawn to this disease after my fellowship completion as a staff physician at the Minneapolis VA Medical Center, where the majority of our inpatient consults tended to be either sick people with vasculitis and lupus or people with gout flares and concomitant septic arthritis in gout or a question of gout or management of gout.
So, I clearly sensed that there was a big need for understanding this disease and controlling it better, and I got drawn into research as I saw other people in the field who were very passionate about this research, including Ralph Schumacher, Michael Decker, and obviously you as well, Larry, through my connections to all three of you through the Omri.
So, I still feel like there’s a lot to be done in this field, and I continue to enjoy working in this disease, disease mechanisms, and treatment, and still find it very exciting and an important area to continue to work in, both as a clinician and as a researcher.
Dr. Larry Edwards
Thanks, Jas. We’re delighted to have you with us today. In our previous three podcasts that we’ve done for the Gout Education Society, we focused on how gout affects a person’s health and happiness.
For this episode, I’d like us to focus instead on how gout may affect a person’s wallet, and in that regard, look at the costs of gout, the direct costs as far as doctor’s visits, laboratory testing, hospital visits, medications, and the indirect costs as far as being absent from work. Then, I think we could discuss a little bit on whether or not early management, treatment, and recognition of gout could reduce some of these economic burdens for patients who have gout.
Can you tell us a little bit about these direct costs and indirect costs?
Dr. Jasvinder Singh
Yeah. So Larry, I think that is really a very important aspect of gout management. The direct cost obviously hits the patient right in the pocket and makes it challenging for patients to take good care of the condition. And there are humongous amounts of indirect costs in gout, primarily because it’s not recognized as a serious disease or a chronic disease. And many times, patients and sometimes even providers in the initial few years of gout think of it as separate acute attacks by years and not requiring treatment. And that’s what leads to a significant impact on work productivity, days of work lost. People might have challenges keeping their jobs because of recurrent attacks and not being able to show up at work.
It has impacts on their social lives in addition to having direct effects on productivity, and that’s what leads to a lot of indirect costs of gout. The reason we have humongous amount of indirect costs from gout is related to not only the fact that gout is the most common inflammatory arthritis in adults, but also that it may not get the same respect and attention that something similar to it, like rheumatoid arthritis, gets in terms of the need to treat the target and manage it and keep it under control.
Keeping gout under control obviously will lead to fewer flares and less effect on quality of life, less pain, better function, but also better productivity and fewer days of work loss in absenteeism and decreased presenteeism, both at work and for people at home who are running and taking care of their families.
We are also aware of a lot of research that has already shown us that people who have gout with frequent flares tend to accumulate both a higher direct cost out of pocket, as well as higher indirect costs due to all of these downstream effects. Better management, potentially, to treat the target, an approach where you have a goal for the patient to get their disease treated and kept under control, has the potential to decrease not only the humongous indirect cost, but also the direct cost of this. Some of this comes from expensive urgent care, emergency room, inpatient visits, and hospitalizations, a majority of which can be avoided and lead to not only cost savings, but also better outcomes for the patient and less resource utilization overall.
Dr. Larry Edwards
Sure. A lot of this stems from what you mentioned earlier, that the disease itself. Gout, although it’s excruciatingly painful and a major disease to those that have it, a lot of times healthcare providers view it as not as important as the other comorbid conditions like blood pressure, kidney disease, and heart disease that these patients may also have.
I think getting focused early on and making it imperative that, not only do we have a firm diagnosis that what the patient’s complaining about is gout, but also that they have a care provider that understands the importance of treating this, not just to eliminate the flares, but also to help control the other comorbid problems like the diabetes and blood pressure as well. Yeah, I think that’s the case. If we could treat everybody early, then this would be a rather inexpensive disease to have cured, but it’s unfortunately not that way.
Let’s turn from those costs and talk about the barriers to treatment access and the role this plays in the overall socioeconomic impact of gout. We know that the overwhelming percentage of gout patients are initially seen and cared for by primary care physicians, like GPs, family medicine internists, and ER physicians, especially in the early stages of gout. Patients who have more advanced disease or those who don’t respond well to initial therapies for the gout are frequently referred to arthritis specialists or rheumatologists.
How are the economics of gout affected by this referral pattern?
Dr. Jasvinder Singh
I think that, as you correctly stated, the majority of gout is cared for by primary care physicians and only those that they think are not optimally controlled are referred to rheumatologists. But this does reflect the harsh reality, which is that there’s a lack of a big army of rheumatologists available in the United States, at least. There’s a shortage of rheumatologists, and, therefore, access to rheumatology care is somewhat limited in many parts of the country. Even in parts of the country where you have a lot of rheumatologists, such as in big cities, they have long wait times. Primary care providers frequently refer all of their rheumatoid arthritis patients and lupus patients to rheumatologists, but not every gout patient.
I think one of the other issues that surprises you and me a lot is that we don’t have lots of folks focused on gout. A lot of rheumatologists are focused on gout. Obviously, this is something that is a passion for you, me, and several of us, that a lot of rheumatologists sometimes may be interested in autoimmune diseases like lupus, or RA, spondyloarthritis, or vasculitis. And therefore, there are not a lot of rheumatologists who are very interested in gout itself. Both the perception and interest of rheumatologists and primary care physicians’ own confidence may lead to the failure of only a small group of, or a small proportion of all patients with gout, to see a rheumatologist.
How does it affect overall? I think that a lot of times, at least of those that get referred to my colleagues and me, we believe that we wish those patients had been referred to us two years ago, five years ago, 10 years ago, or a year ago, where we could have done a much better job treating their disease. Which makes me think, Larry, that there’s probably a large proportion of other patients who never get referred to you and me who might also benefit from this.
Now, having said that, as I said, access to rheumatologists is limited, and even if primary care providers started referring double the number of patients or three times the number of patients, there still would be challenges to get them through rheumatology care. Maybe that would get some rheumatologists interested in this more.
I think what could really help us is if primary care and and rheumatology as fields could work together and if primary care physicians could get guidance or change their practice patterns or have a conversation with a rheumatologist with regards to what they can do while they’re managing these patients for years or waiting for them to be seen by rheumatology is to get a pattern of care and early, and treat to target management style in their own practice. And giving that importance to gout management as they give to the treatment of their heart disease, their COPD, and their heart failure. If you give it the same respect as a disease, then perhaps it would reduce the burden on the patient and the resulting burden, both economic and resource-wise, on the healthcare systems.
And obviously, it will make a lot of gout patients’ quality of life better. It would allow them to function better, participate in social activities, and family in terms of discharging their responsibility as family members and being active contributors to both the community and their family in a much more efficient way and to their satisfaction than a lot of patients are currently able to do.
Dr. Larry Edwards
I’m nodding, per the cost that we had talked about a little bit earlier as well. Yeah, it’s relying on the referrals from primary care. To me, this disease is one, curable. We know so much about it, unlike a lot of the other diseases. We know the underlying reason that this inflammation occurs. We know that the very basic treatment that’s been with us for 60 years in the form of allopurinol can reduce the uric acid elevations that are really the center of all of this.
The problem is, in survey after survey of knowledge bases of primary care physicians relative to rheumatologists, the primary care physicians don’t fare as well, as they don’t know as much about the underlying disease. They generally recognize that it’s a chronic disease, that it’s something that should be treated. But like you say, a lot of times it’ll wait until it really becomes a real imposition on the patient, with frequent, every two to three to four months, having flares and being absent from work. There are some very basic things that I think primary care physicians could be doing, even in the most complicated of gout patients, and take that into their hands.
Dr. Jasvinder Singh
I agree with you, Larry, that we’d really would do a big service to the patient community if primary care physicians could handle most of the gout in their practices, but with a slightly different strategy that’s more targeted in terms of goal, treatment goals, which is less than to eliminate flares, to get their uric acid to a certain level, to the target as recommended by guidelines and things. But, also, I think, in general, to give this disease the respect that it deserves.
I think that a lot of times I see, and I’m sure you must have seen, there’s a long problem list, and it’ll come at the bottom, and it basically says, “Continue the same treatment.” And while that is not, by itself, a problem when the treatment is optimal, continuous treatment is a problem when the other treatment is not optimal. While cardiologists and others have succeeded in communicating with their primary care colleagues how CDID needs to be aggressively treated, I think we still have some gaps and some more work to do to convince our primary care colleagues that this disease, which is simpler to treat than coronary artery disease, needs similar attention and a different way of managing it, maybe with the same medication that will make things much better for them and their patients.
Dr. Larry Edwards
Yeah. That kind of leads us into our final point of discussion today, Jas, and that’s just about educating professionals as well as patients.
I think it’s clear that the education of both those groups, of the medical professionals and patients, is the key to improving the quality of life that gout patients suffer. For this last topic, if we could just think about what would be the best approach to have our healthcare colleagues look at and understand the treat-to-target guidelines that the American College of Rheumatology, and essentially all international professional organizations have developed these, the same guidelines for managing gout, of how to spread that around, and also encourage patients with gout to understand more about their disease so they know why they’re taking various medications that they’re on and why they need to stick on those for a lifetime.
Dr. Jasvinder Singh
Yeah, I think that those are key aspects of what can improve patients’ quality of life. I’m well aware of all the work that has gone into looking into the evidence base for what’s available for efficacy and comparative efficacy of all the treatments for gout, which has been incorporated into the ACR guideline. There are British Society guidelines. There are EULAR guidelines for the management of gout, and I think that these are still the best evidence-based guidelines that we all look at and follow, which clearly provide us with goals of treatment. They help us understand why certain actions may be more desirable because they have better evidence behind them.
Folks can look at this guideline and incorporate it into their practice. Obviously, you can tailor it to a patient’s particular situation when they have additional comorbidities or a special situation, and can tailor the therapy within the context of what the guidelines are providing you, what is evident based on, and what you need to do for the patient. I think having a discussion with the patient when you’re seeing them for their primary care visit once a year, about their gout, how it affects their life, talking to them about their gout medication and adherence to it, as you talk about their high blood pressure medication adherence to it.
You know, there’s, again, another disease where if you have an open conversation with a patient, you’re much more likely to understand why they do not take their medication and have an open conversation about what things one might be able to do that could enable the patient to do a better job of managing their condition and being in control and making progress and avoiding long-term complications and disability that comes as a result of untreated gout or suboptimally treated gout.
Patients need to be convinced that this is not a treatment they can stop and start because that will not do them as well as it would with good management and long-term. A lot of times, patients have doubts, and unless the physician addresses them head-on, I think patients will take the medications any which way that matches their own, their own values and preferences, which may not always be in the patients’ own best interest.
So, I think a frank conversation with regards to the impact on the benefit of maintaining good treatment, maintaining uric acid below a certain level based on the guideline, emphasizing that this is a lifelong disease that requires almost a lifelong treatment that will keep them flare free and might even have other added benefits of avoiding inflammation that spills over from joint to other parts of the body cumulatively over time are additional incentives for patient to think of treating their gout with a good regimen and taking their medications regularly.
I think having a partnership with the patient, as a primary care physician, as a rheumatologist, is key, and allowing the patient to share why they may not want to take their medications every day and what the barriers are can go a long way. I think that, at the very least, it makes the provider aware of why they’re not getting to the same control of the disease that they wish or expect to have. Medications, in terms of adherence, have always had an issue for long-term treatment of any chronic disease, and this being a chronic disease, the patient may not feel symptoms every day.
Patients are very likely to question and doubt why they need treatment every day when they don’t feel the symptoms every day. So, I think those are the things that physicians need to clearly communicate to patients that the disease is chronic, even though the symptoms may not manifest every day. The effects of the disease are there. Medication is a way to control the ongoing symptoms and also potentially prevent long-term radiographic damage and disability that comes as part of this disease.
Dr. Larry Edwards
In fact, this is one of the few chronic diseases that can actually be cured by adherence to the gout regimen. The patients themselves, wanting to know what good coverage, what good care is for their gout, can go to the Gout Education Society’s website. We have good descriptions there and emphasize the fact that taking their uric acid-lowering therapy is central to the good things that we can do to cure this process.
Patients should know what their uric acid level is and know that their treating physician shouldn’t be satisfied with the current regimen unless the uric acid level is less than six milligrams per deciliter. Those are things that the patient can take into their own hands, and it empowers them to be in control of their disease. Yeah, I think that there are a number of approaches to this, and not just websites, but I think that there are chat groups around that can share anything. I run a Reddit subgroup for gout patients and discuss all these issues, like the one you mentioned, really not wanting to take a medicine every day for the rest of their life. We have good discussions about that sort of thing.
Jas, is there anything else that we should be discussing on this particular podcast before we wrap things up?
Dr. Jasvinder Singh
I think you’ve covered the major challenges, Larry, during our discussion. I think that one of the other things that I’d like to mention briefly is that there’s been lot of new knowledge in the field of gout in the last one to two decades in addition to new therapies and options becoming available, and therefore, we are much further along this path of putting people with gout in remission or cure status than we were let’s say 20, 30 years ago. We can do that much better now than we used to.
There’s also a lot of emerging evidence regarding what inflammation does to other parts of the body outside of the joint. And I think in the coming years, we’ll probably see evidence of why ongoing inflammation, which is a hallmark of gout, is not good for the body. It’s not just a detriment to the joints. What we might be doing with gout treatments for our patients may have some additional beneficial effects above and beyond the joint in the next five to 10 years.
What does that evidence show as we get more sophisticated in asking those questions and investigating those in our patients? I’m hoping that we get a lot more progress and interest from the pharmaceutical industry in developing and bringing more therapies and different mechanisms targeted for new therapies that can help us take care of the few patients who are still very refractory to all the available treatments that we have.
We also need to surrender to the fact that a majority of our issues is not lack of treatments, it is the adherence issue, the knowledge gap, and perhaps in the elderly patient population, the multi-comorbidity that is sometimes challenging, but in that order. So, I think the top two or three reasons in my mind are all modifiable and could be addressed by primary care physicians and rheumatologists, and in the majority of cases, primary care physicians or primary care colleagues. So, if we can work together with them, then patients with gout can have a much better life and can enjoy things with their family that are sometimes put on hold just because of the fear of an attack of gout.
Dr. Larry Edwards
Yeah. Those are all excellent comments, Jas, and I thank you for joining us today. It’s been delightful. Our hope is that conversations like this help people with gout feel empowered about taking care of their disease and making sure that they’re getting the best current knowledge treatment that they can. Ian, we’re turning it 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
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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.
