Gouty Arthritis: Expensive and Hard to Treat

By Jennifer Anderson

Gout, or gouty arthritis, the most common inflammatory arthritis in men and women, can be difficult to treat and more than double the cost of health care, according to recent studies.

In February, a literature review from Canada concluded that the presence of gout increased direct costs for certain patients by as much as 150%. Those patients, who are treatment resistant, experienced approximately $18,000 in direct costs in US dollars compared with $7,188 for similar patients without gout. 

Looking only at elderly patients, those with gout had per capita costs of approximately $16,900 compared with $10,590 for those without gout, according to the study by Sharan K. Rai, of Arthritis Research Canada and colleagues, and published in Seminars in Arthritis and Rheumatism.

For employed patients, the cost jumped from $2,562 to $4,733, the study concluded.

In a review paper published in 2011, Naomi Schlesinger, MD, chief of the division of rheumatology at Rutgers Robert Wood Johnson Medical School, described a "significant economic burden" associated with gout, especially for those patients whose disease is difficult to treat.

In addition to cost, a data analysis showed patients with gout missed work approximately five additional days per year compared with patients who did not have gout, Schlesinger wrote in the paper, which was published in Drugs. 

Hospitalizations for patients with gout increased from 115,000 in 1998 to 446,000 in 2005. In a 2007 paper, published in The Journal of Rheumatology, Schlesinger describes the cost increase for hospitalization as "dramatic"—jumping from $760 million 1998 to $11.2 billion in 2005.

Proper treatment for patients with gout is critical. Indeed, the Canadian study noted that costs decrease when patients are treated well.

"We need to be mindful of treatments that are contraindicated, largely because of the presence of comorbidities," Schlesinger says. She explained that many patients are treated with combination anti-inflammatory agents despite underlying comorbidities, which can include metabolic syndrome, hypertension, dyslipidaemia, obesity, cardiovascular disease, diabetes, and renal impairment. 

A Royal Disease
Once considered a disease of kings and others with access to plenty of food and drink, gout now affects even the commoners, especially as people are all living longer, Schlesinger says. With new drugs available to treat gout and more studies addressing the disease, interest in gout is "coming out of the woodwork," she says.

Gout affects more men than women, and while it can occur in any joint, the first presentation in men is usually in the lower extremities, Schlesinger says. In older women, it's usually in the hands and knuckles.

When the disease flares, the pain is severe—what patients have described as akin to fire or walking on glass, Schlesinger says. In fact, legend has it that when Roman Consul Marcus Agrippa felt his fourth bout of gout coming on, he committed suicide rather than endure the pain, she says.

Start Low and Go Slow
Gout usually flares in the early morning hours, when body temperatures are lowest, explains Mitra Hashemi, MD, an internal medicine specialist with Adventist HealthCare. The pain is excruciating, she says, and can settle in any joint, with some patients unable to tolerate even the weight of the bed sheets on affected areas.

In addition to flares, gout is a chronic condition arising from elevated levels of uric acid, a byproduct of purine, which is produced by cells and is also found in foods. The elevated uric acid can lead to crystal deposits in the joints, causing the painful flare-ups, Hashemi explains.

Some foods, notably beer and other alcoholic beverages, red meat, and high-fructose corn syrup, can elevate levels of uric acid. Some people have a genetic predisposition to gout.

The disease can be particularly difficult to treat because of potential side effects of the medications, which can exacerbate kidney problems and other comorbidities, Hashemi says.

Treatment for gout is twofold, Hashemi explains. First, the acute flare must be treated, usually with colchicine, NSAIDs such as indomethacin, or steroids that are typically injected into the joint, taken orally, or through IV. The choice of therapy is based on different factors, notably the patient's age, comorbidities, and list of other medications. 

"We need to be careful in the elderly as they usually have other comorbidities including kidney disease and heart disease," Hashemi says.

Although NSAIDs and colchicine are commonly used to treat gout flares, these are among medications that can be problematic in elderly patients and those with kidney conditions, she says. 

Following the flare-up, urate-lowering agents must be initiated, she says, including medications such as allopurinol, febuxostat (uloric), and probenecid. "This part of the treatment is very important and frequently ignored," she says.

Uric acid levels are typically monitored through a blood test to ensure the appropriate medication dose is being used, Hashemi says. "In the elderly, it is important to start with a low dose and go up slow; however, a certain dose is needed to control the future gout flare."

Hashemi explained that uric acid levels should be 6 milligrams per deciliter (mg/dl) or lower. Normal uric acid levels are 6 mg/dl in women and 7 mg/dl in men. In severe gout cases, the level may need to be kept below 5 mg/dl, she says.

On occasion, efforts to lower the uric acid can inadvertently cause a flare. When this occurs, it is important to continue the uric acid-lowering medication, she says. 

In the future, interleukin blockers and other medications now in clinical trials in the United States may provide better treatments not only for flares but also for the chronic inflammation that promotes flares. A 2011 study found that canakinumab reduced the risk of acute gouty arthritis flares during initiation of allopurinol therapy.

Hashemi concurs that the number of gout cases is on the rise, partly because of the rise in obesity, kidney disease, and other comorbidities. She adds that diuretics commonly prescribed for hypertension and heart disease also can increase uric acid levels.

"As with any medical condition, you have to evaluate the risks of the medication vs the benefits," she says. "Treating gout should not result in more problems."

Future Directions
While a blood test can determine serum urate levels, only one-third of patients with elevated levels of uric acid will suffer from gout, Schlesinger says.

Ultrasonography and Dual Energy CT (DECT) may serve as a noninvasive means to diagnose gouty arthritis in hyperuricemic individuals who have yet to develop symptoms of gout. But no one knows how long hyperuricemia must be present before the crystal deposits in the joints can be seen sonographically or via DECT. 

And even if the crystals have been imaged before the development of acute flares, it's not clear whether patients can benefit from immediate initiation of urate-lowering therapy and chronic anti-inflammatory treatment.

Most people who suffer an initial flare will have a second attack within the next two to three years, according to Schlesinger. The more attacks a patient experiences, the more likely he or she is to have additional attacks, she says. Patients who seek treatment within the first 24 to 48 hours are most likely to experience relief.

With proper treatment hyperuricemia can be brought to target levels, and the inflammation can be controlled to prevent further flares.

— Jennifer Anderson is a freelance health and science writer based in Falls Church, Virginia.