Introduction
Gout is a complex type of arthritis associated with different symptoms and causes. It is characterized by sudden acute pain, swelling, redness, and tenderness of one or more joints, most commonly the big toe. Gout attacks can strike without warning, and when you wake up in the middle of the night, your big toes feel like they are burning. Even the weight of bed sheets in affected joints may look uncomfortable because it is hot, puffy, and soft. The symptoms of gout appear and disappear, but there are strategies to control them and avoid recurrence.
Gout occurs when body tissue becomes supersaturated with uric acid, resulting in monosodium uric acid crystals (MSU) in and around the joints. It is a common variation of inflammatory arthritis in men and is associated with poor quality of life. The tolerable and painful acute attacks of gouty arthritis, the formation of localized MSU crystal deposits in joints and other body tissues, persistent joint injury, renal stone formation, and the possibility of renal failure are all clinical manifestations.
Causes
Gout happens whilst urate crystals build up on your joints, generating irritation and excruciating pain. When your blood has an excessive amount of uric acid, urea crystals can form. When your frame breaks down purines, which might be chemical substances observed evidently on your frame, uric acid is produced (Saito et al., 2021). Purines also can be observed in a few foods, which include beef and organ meats like liver. Anchovies, sardines, mussels, scallops, trout, and tuna are examples of purine-wealthy seafood. Higher quantities of uric acid are promoted via way of means of alcoholic beverages, especially beer, and liquids sweetened with fructose (Xu et al., 2018). Uric acid dissolves in the blood and normally flows from the kidneys into the urine. However, the body may produce too much uric acid, or the kidneys may excrete too much uric acid. Uric acid can accumulate in joints and surrounding tissues, forming sharp needle-shaped uric acid crystals that can cause pain, inflammation, and swelling.
Risk Factors
If one have a lot of uric acid in the body, they are more likely to get gout. Diet, weight, medical condition, specific medications, goat family history, age, gender, recent surgery, and trauma are all factors that can increase uric acid levels in the body (Dehlin et al., 2020). Gout is more commonly found in men than in women because of its low uric acid levels. On the other hand, female uric acid levels approach that of postmenopausal, male uric acid levels. Men are also more likely to develop gout symptoms earlier in life than women, but women often develop symptoms after menopause (Dehlin et al., 2020). Episodes of gout can be caused by recent surgery or trauma. Vaccination can cause gout attacks in certain people in different cases.
A diet high in lean meats, fish and shellfish, and fructose-sweetened drinks increase uric acid levels and increases the risk of gout. Gout is also exacerbated by drinking alcohol in great amount, especially beer. If a person is overweight, their body makes more uric acid, and their kidneys have a hard time getting rid of it. Gout is exacerbated by certain disorders and situations (Dehlin et al., 2020). These include untreated high blood pressure and chronic illnesses such as diabetes, obesity, metabolic syndrome, and heart and kidney disease. Low doses of aspirin and various antihypertensive drugs such as thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers can increase uric acid levels. Rejection drugs prescribed after an organ transplant can also cause problems. If a patient’s family members have experiences gout disease, they are more likely to develop gout.
The Magnitude of the Problem
Gout is prevalent in 1-4% of the world’s population and has been shown to have an incidence of 0.1-0.3%. Gout is common inflammatory arthritis, affecting about 4% of the population in the United States (Knee Surg, 2020). Gout is 3 to 10 times more common in men than in women (Singh & Gaffo, 2020). The incidence and prevalence of gout increased every ten years of life, reaching 11-13% prevalence and 0.4% prevalence in adults over 80 years of age (Singh & Gaffo, 2020). Gout is more common among ethnic minorities in the United States, New Zealand forests, Han Chinese, and other ethnic communities in Asia (Singh & Gaffo, 2020). Comorbidities often occur in people with gout and make it difficult to manage and outcome the disease. Hypertension is found in up to three-quarters of gout patients and can play a role in association with cardiovascular disease and stroke. Gout is the most common adult inflammatory arthritis in the world, affecting disproportionately men, the elderly, and race/ethnic minorities. Comorbidities of gout are very common, increasing the prevalence of the disease and making it more difficult to treat.
Racial/Ethnic Class Variations
The incidence and prevalence of gout are high among racial/ethnic minorities. The incidence of gout in African-American men was 3.11 per 1000 man-years, compared to 1.82 per 1000 man-years for white men (Singh & Gaffo, 2020). Cumulative incidences were 10.9 percent and 5.8 percent, respectively (P = 0.04). The relative risk of gout in African-American men is 1.69 (95% confidence interval: 1.02–2.80), which can be partially explained by the fact that African-American men have high hypertension rates (Singh & Gaffo, 2020). It was found that the prevalence of gout was 4.0% (95% CI, 3.34.8%) in Caucasians and 5.0% (95% CI, 3.36.6%) in African Americans (Singh & Gaffo, 2020). This was reflected in the fact that African Americans had a higher prevalence of hyperuricemia than Caucasians. Among people aged 45-65 years (born in 1987-1989), African Americans had gout more than Caucasians (Singh & Gaffo, 2020). Adjustment of serum uric acid was associated with a slight reduction in the association between race and the incidence of gout.
In Minnesota, the prevalence of self-reported gout among Hmong Chinese was 6.5% vs. 2.9%, twice the prevalence of the general population in the United States (Singh & Gaffo, 2020). Gout was more common in Hmong men than in non-Hmong men, at 11.5% compared to 4.1% (Singh & Gaffo, 2020). Hmong Chinese ethnicity is significantly associated with the risk of local gout when adjusted for age, gender, hypertension, diuretic use, and renal function, with an odds ratio of 4.3 (Singh & Gaffo, 2020). Similarly, the New Zealand forest community has a much higher prevalence of hyperuricemia and gout than people of European descent, and 50% of New Zealand’s Polynesian population suffers from hyperuricemia in New Zealand. Ten percent of adult men in New Zealand are suffering from the gout disease.
The study compares the natural and clinical course of gout between African Americans and Caucasians (Singh & Gaffo, 2020). African-Americans have shown in a longitudinal study of samples of gout patients in two cities (Birmingham, Los Angeles) that they are inferior to whites in general and gout-specific quality of life and function. This study suggests that racial/ethnic minorities are at increased risk of condition severity. A prospective cohort study of gout in the United States is needed to properly represent minorities and women.
Yearly Cost of the Problem
Maintaining a prescribed treatment and taking care of the patient might require certain costs. The average direct out-of-pocket cost (OOPC) for gout was AU$666, and the median annual direct OOPC was AU$200 (Nathan et al., 2020). Prescription drugs (AU$207), non-prescription drugs (AU$87), and traditional Chinese drugs (AU$84) were the three categories that contributed most to the average annual cost (Nathan et al., 2020). These accounted for 57% of total direct costs, or an average of A $ 378 (Figure 1). The median direct medical expenses were $ 200 (IQR: $ 60, $ 570), while the median non-medical expenses were $ 0 (IQR: $ 0-15). All medications, medical consultations, diagnostic imaging, pathological examinations, medical procedures, and hospitalization are included in medical expenses. Transportation and home medical expenses were the most commonly recorded non-medical direct expenses. In the last 12 months, if absent or lost working days due to gout, the median lost a quarter of the working days.
In a study conducted by Nathan et al (2020), nearly 10% of respondents said they would not be treated for gout because they could not afford treatment and medication. Measured direct medical costs for gout patients may have been reduced because gout patients were unable to purchase gout medications or attend consultations with medical professionals. In our study, not all patients with cost-related treatment attrition (CRTA) were able to purchase gout medication. Patients with gout may enter a cycle of financial inability to provide treatment that can control or eliminate the symptoms of the disease, and as a tendency towards the severity of gout, the disease worsens and leads to higher spending on treatment. The increase in OOPC can be combined with CRTA. SAI and control of gout attacks have been shown to reduce gout-related costs and improve the overall quality of life of gout patients. Finally, more work and investigations are required to make gout treatment more accessible.
A regional study was conducted by Sigurdardottir et al. (2018) from January 2000 to December 2012 on the population management of 4,571 working-age gout patients who were first diagnosed with gout from 2003 to 2009 and 22,482 by age, gender, and place of residence. It was conducted using data from Sweden’s national and regional registrations up to the month. Three years after identification, Sigurdardottir et al. (2018) have calculated differences in initial parameters (education level, income, previous employment, comorbidities), and the number of days lost due to sick leave and disability pension. Using conditional logistic regression, a new predictor of absenteeism (> 90 days/year) within a subset was found.
Patients with gout (median age 53 years) had significantly more comorbidity, lower-income, and lower education levels than comparable controls (Sigurdardottir et al., 2018). During the 3-year follow-up period, gout patients had higher average absenteeism than controls (P0.0001), 22% and 14%, respectively (Sigurdardottir et al., 2018). Multivariate analysis found that gout was a significant predictor of new absenteeism. Other factors independently associated with the new absence were attendance at school under the age of 12, previous unemployment and illness, and various comorbidities (kidney disease, cardiovascular disease, alcohol abuse, and obesity).
Treatment
Gout remedies fall into two categories, each addressing a different problem. The first type helps relieve the pain and inflammation associated with gout attacks. The second type helps reduce the amount of uric acid in the blood and prevent gout problems. The frequency and intensity of the patient’s symptoms, as well as other health problems that the patient may have, determine which drug is best for the patient. Nonsteroidal drugs, colchicine, and corticosteroids are one of the drugs used to treat gout attacks and prevent future attacks.
Nonsteroidal anti-inflammatory drugs (NSAIDs) include over-the-counter analgesics such as ibuprofen (Advil, Motrin IB, etc.) and naproxen sodium (Aleve), and powerful prescription analgesics such as indomethacin (Pillinger & Mandell, 2020). Abdominal pain, bleeding, and ulcers can be side effects of NSAIDs. Colchicine (Gloperba, Mitigare), an anti-inflammatory drug that is effective in relieving the symptoms of gout, may be prescribed by a doctor. However, side effects such as nausea, vomiting, and diarrhea can reduce the effectiveness of the drug. Prednisone and other corticosteroids help treat gout inflammation and pain. Corticosteroids can be taken as tablets or injected directly into the joints. Mood swings, high blood sugar, and high blood pressure can be side effects of corticosteroids.
If the patient has multiple gout attacks each year, or if the gout attacks are less but more painful, the doctor may prescribe medication to reduce the risk of gout problems. If the patient has evidence of gout injury on joint X-rays, and if he has gout nodules, chronic kidney disease, or kidney stones, uric acid-lowering drugs can be prescribed. Allopurinol and febuxostat (urologic) are drugs that help the body reduce uric acid (Pillinger & Mandell, 2020). Fever, rash, hepatitis, and kidney problems are all side effects of allopurinol. Rash, nausea, and decreased liver function are all side effects of febuxostat. Febuxostat can also increase the risk of dying from a heart attack. Probenecid (probenecid) is a drug that improves the ability of the kidneys to excrete uric acid from the body. However, rashes, abdominal pain, and kidney stones can be side effects.
Barriers to Treatment
Knowledge gaps and management skills, views and beliefs about gout patients, and systematic obstacles to optimal gout care were identified as the top three topics addressed by the provider. Limited knowledge of gout, contact with healthcare providers, attitudes and experience of taking medication, and practical barriers to long-term substance use have also been found to be common problems for gout patients (Rai et al., 2018). The extensive review of the global literature often provides knowledge of gout among clinicians who are likely to contribute to inadequate patient education on the underlying causes of gout and important approaches to treatment (Rai et al., 2018). In addition, there are significant system hurdles between providers that pose daily challenges for patients on long-term medication. These criteria are important goals in improving the general lack of gout care.
Time limits have been identified as a major obstacle to successful gout management. Health providers, especially general practitioners, said they lacked time to provide appropriate gout education to patients (Rai et al., 2018). Financial incentives may be needed to improve long-term gout care. Finally, linguistic and cultural issues were cited as additional barriers to gout care, making it more difficult for each patient due to the limited time available.
Study carried out by Rai et al. (2018) suggests that barriers to care, providers, and patients, are intertwined, especially with regard to the important knowledge and education gaps associated with illness and its treatment. These gaps in the care provider’s expertise can contribute to patient misunderstandings about the reasons for gout and the treatment options available. For example, patients were unaware of the role of uric acid in the development of gout, the availability and correct use of curative ULT, and the risk of paradoxical recurrence at the onset of ULT. Similar information gaps were found in previous studies of gout patients.
Conclusion
Gout is a chronic disease of the joints characterized initially by recur-rent inflammatory reactions or flares in response to the formation of urate crystals in joint spaces in individuals with high serum uric acid (UA) concentrations. There are several factors influencing the occurrence of gout disease; however, the main cause is the excess of uric acid in the body, known as hyperuricemia. Once purines are broken down in the body, the production of uric acid, which is then found both in the body and food begins. Risk factors of the disease are mainly associated with the diet, medical conditions, age, and sex of a person. In addition, such factors as ethnicity and economic status also affect the outcome of the disease.
Despite the fact that there are different medicaments used in the current treatment, there are still barriers associated with the effective treatment of gout disease. They are a lack competency in management and do not have enough understanding of the disease in patients. The gout disease is widely spread all around the world and has a big magnitude. For many people, it might create difficulties to afford the treatment due to the yearly costs of the disease treatment. In order to prevent the further spreading of gout disease and eliminate the treatment obstacles, it is essential to develop awareness about the disease among people and take measures to improve management skills in healthcare.
References
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Nathan, N., Nguyen, A. D., Stocker, S., Laba, T. L., Baysari, M. T., & Day, R. O. (2021). Out‐of‐pocket spending among a cohort of Australians living with gout. International Journal of Rheumatic Diseases, 24(3), 327-334. Web.
Pillinger, M. H., & Mandell, B. F. (2020). Therapeutic approaches in the treatment of gout. In Seminars in Arthritis and Rheumatism, 50(3), 24-30. WB Saunders. Web.
Rai, S. K., Choi, H. K., Choi, S. H. J., Townsend, A. F., Shojania, K., & De Vera, M. A. (2018). Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies. Rheumatology, 57(7), 1282–1292. Web.
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Xu, N., Huang, X. M., Fang, W. G., Zhang, Y., Qiu, Z. Q., & Zeng, X. J. (2018). Glycogen storage disease type Ⅰa: a rare cause of gout in adolescent and young adult patients. Zhonghua nei ke za zhi, 57(4), 264-269. Web.