Podcast: Gout: A Primary Care Primer

Gout is a primary care disease. About 70% of patients with gout are treated exclusively in the primary care setting. And because the prevalence of gout is rising, particularly in older patients, you are increasingly likely to encounter this disease in your practice.

In this 3-part series of informational podcasts, I discuss how the current understanding of gout is changing and how this affects the management of the disease:
•Part 1 is an overview, in which I describe the pathogenesis of gout and the risk factors for the disease.
•Part 2 focuses on diagnosis; here I offer real-world advice about when and how to make a presumptive diagnosis, indications for synovial fluid analysis and other studies, and which disorders to consider in the differential.
•In part 3, I map out the options for relief of acute attacks and for prevention of future ones.

Gout: A Primary Care Primer, Part 1
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Part 1, Overview
In this first podcast, I review the definition of gout and discuss the clinical implications of serum uric acid levels. Be aware that laboratory reference ranges for serum urate can be misleading.

Gout is the disease state resulting from the deposition of monosodium urate crystals in tissues, which occurs at a serum urate level of at least 6.8 mg/dL. Hyperuricemia in the absence of crystal deposition is not gout. My take-home message: asymptomatic hyperuricemia generally does not require treatment.

For gout to develop, an elevated serum urate level along with local factors, such as trauma, must be present. What are the risk factors for gout? Among the factors that predispose patients to this disease are:
•Male gender, although the disease is equally common in postmenopausal women.
•Older age.
•End-stage renal disease.
•Diet, including consumption of red meat, organ meat, seafood, and products that contain high-fructose corn syrup.
•High alcohol intake, particularly beer.
•Use of drugs such as cyclosporine, thiazide diuretics, and low-dose aspirin.
•Certain genetic influences, which are not well understood.

What we have now is a “perfect storm” for an increase in the prevalence of gout in the United States. Contributing factors include:
•Increased longevity.
•Increased prevalence of hypertension, obesity, metabolic syndrome, diabetes, and renal disease.
•Iatrogenic causes such as increased use of cyclosporine and thiazide diuretics.
•Dietary trends, including the widespread presence of high-fructose corn syrup in many prepared foods.
•Limited therapeutic armamentarium. 
 

Disclosure:
Dr Lieberman reports that he is on the advisory board of and a speaker for Takeda Pharmaceuticals North America, Inc. He is also a consultant to URL Pharma, Inc.