Gout Flare Burden, Diagnosis, and Management: Navigating Care in Older Patients with Comorbidity

Outpatient Gout Follow-up After an Emergency Department Visit for Gout Flares

OBJECTIVE

Gout follow-up after an emergency department (ED) visit for gout flare may improve outcomes, which could be influenced by demographics and social determinants of health. We aimed to determine the factors associated with outpatient gout follow-up within our health care system within 6 months following an ED visit for a gout flare.

METHODS

This historical cohort study was conducted at an academic medical center that includes 3 EDs and 1 urban urgent care. Among patients with a gout flare during their ED visit, we determined the presence/absence of an outpatient visit for gout within 6 months of the ED visit. We reported the proportion of patients who received outpatient gout follow-up. We used multivariable logistic regression to test the association between key covariates and outpatient follow-up for gout.

RESULTS

From September 2021 to August 2022, we analyzed 159 patients with gout flare at the ED visit, of whom 56 (35.2%) had an outpatient visit addressing gout within 6 months. Being married (odds ratio [OR], 2.66; confidence interval [CI], 1.25-5.68; p = 0.01), absence of comorbidities (OR, 3.86; CI, 1.01-14.71; p = 0.048), use of colchicine at the ED visit or discharge (OR, 2.67; CI, 1.18-6.02; p = 0.02), and increased age (OR, 1.44; CI, 1.15-1.82; p = 0.002, for each 5-year increase) were associated with increased odds of gout follow-up.

CONCLUSIONS

Among a cohort of patients seeking urgent/emergent care for gout flare, only one-third followed up for gout in the outpatient setting. Modifiable factors such as colchicine prescription use were associated with gout follow-up, which may represent areas to target in future studies focused on promoting improved outpatient follow-up for gout.

Untargeted metabolomics analysis of the urinary metabolic signature of acute and chronic gout

BACKGROUND

Gout is a common kind of inflammatory arthritis with metabolic disorders. However, the detailed pathogenesis of gout is complex and not fully clear. We investigated the urine metabolic profiling of gout patients by ultra-performance liquid chromatograph quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS).

METHOD

Urine metabolites were extracted from 26 acute gout patients, 31 chronic gout patients, and 32 healthy controls. Metabolite extracts were analyzed by UPLC-Q-TOF-MS for untargeted metabolomics. The peak area of creatinine was used to correct the content variations of urine samples for the semi-quantitative analysis. The value of variable importance in the projection (VIP) was obtained through the orthogonal partial least squares-discrimination analysis (OPLS-DA), and several differential metabolites were screened out.

RESULTS

The potential metabolic markers of gout in different stages were found based on the t-test. Finally, 18 different metabolites were identified through Human Metabolome Database (HMDB) and Targeted-MS/MS. The receiver operating characteristic (ROC) curve results revealed that all the screened biomarkers exerted high accuracy and diagnostic value. Pathway analysis indicated that the significantly different metabolites were mainly involved in purine metabolism and amino acid metabolism.

CONCLUSION

The identified potential biomarkers are mainly involved in purine metabolism and amino acid metabolism, which leads us to further explore the pathogenesis of gout. This will lead us to further explore the pathogenesis of gout and provide the basis and ideas for the prevention and treatment of gout.

The Therapeutic Management of Chemical and Herbal Medications on Uric Acid Levels and Gout: Modern and Traditional Wisdom

Background: Gout is a chronic inflammatory condition characterized by elevated uric acid levels in the blood, which can precipitate acute gout attacks in individuals with genetic susceptibility, existing medical conditions, and dietary influences. Genetic predispositions, comorbid medical conditions, nutritional choices, and environmental factors increasingly recognize the multifactorial etiology of the disease. Methods: Recent research has highlighted the potential of phytochemicals, particularly flavonoids, saponins, and alkaloids, to manage hyperuricemia (HUA) and its associated complications. Results: Plant's natural compounds have garnered attention for their anti-inflammatory, antioxidant, and uric acid-lowering properties, suggesting their role in alternative and complementary medicine. Phytochemicals have demonstrated promise in mitigating gout symptoms and potentially modifying the disease course by addressing different aspects of hyperuricemia and inflammation. Herbal remedies, with their complex phytochemical profiles, offer a unique advantage by potentially complementing conventional pharmacological treatments. The integration of herbal therapies with standard medications could lead to enhanced therapeutic outcomes through synergistic effects, optimizing disease management, and improving patient quality of life. Conclusions: This review examines the current understanding of the multifaceted etiology of gout, explores the role of phytochemicals in managing hyperuricemia, and discusses the potential benefits of combining herbal remedies with conventional treatments to improve patient care and therapeutic efficacy.

Exploration of the potential mechanism of Yiyi Tongfeng Formula in the treatment of acute gouty arthritis based on network pharmacology and molecular docking: A review

The global prevalence of gout is on the rise. Yiyi Tongfeng Formula (YTF), a traditional herbal compound, has gained recognition for its efficacy in managing acute gouty arthritis (AGA). Despite its widespread use, the underlying mechanisms of YTF in AGA treatment remain largely undefined. This study employed network pharmacology and molecular docking to elucidate these mechanisms. We utilized the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform, SymMap database, and various literature sources to identify active components and corresponding targets of YTF. Relevant AGA-associated targets were identified through the Genecards, Drugbank, Therapeutic Target Database, and Online Mendelian Inheritance in Man databases. A protein-protein interaction network was constructed to delineate interactions between YTF targets and AGA. Key ingredients and central targets were further analyzed using Cytoscape. Functional enrichment analyses, including Gene Ontology and Kyoto Encyclopedia of Genes and Genomes, were conducted via Metascape. Additionally, molecular docking studies were performed using PyMOL and AutoDock4. It was found that quercetin, kaempferol, and luteolin may be the main active components of YTF for AGA treatment. Gene Ontology enrichment analysis shows that the main biological processes involved are cellular responses to lipids, and inflammatory responses. Kyoto Encyclopedia of Genes and Genomes enrichment analysis suggests the involvement of the IL-17 signaling pathway, AGE-RAGE signaling pathway in diabetic complications, TNF signaling pathway, and so on. The findings suggest a multi-faceted therapeutic approach of YTF in treating AGA, involving multiple components, targets, biological processes, and signaling pathways. This comprehensive mechanism offers a foundation for further experimental validation.

The value of musculoskeletal ultrasound in predicting gout flares in index joints: A prospective cohort study of people with gout starting urate-lowering therapy

OBJECTIVES

To evaluate whether ultrasound findings of monosodium urate (MSU) crystal deposition predict frequent gout flares in index joints over 12 months.

METHODS

This single-center study enrolled people with at least one gout flare involving the MTP1, ankle or knee joint. The most painful or most frequently joint was identified as index joint for analysis. All participants were started on urate-lowering therapy and had an ultrasound scan of the index joints at the baseline visit. OMERACT scores (for tophus, double contour sign and aggregates) were used to analyze whether ultrasound scores predicted frequent (≥2) gout flares in the index joint over 12 months.

RESULTS

Frequent flares were significantly higher in those with ultrasound findings in all index joints (MTP1: tophus: 85.0% vs 46.0%, P < 0.001, aggregates: 78.8% vs 59.0%, P < 0.01; ankle: tophus: 54.6% vs 20.8%, P < 0.001; aggregates: 60.0% vs 35.9%, P < 0.05; knee: tophus: 68.4% vs 28.6%, P < 0.05). For the MTP1, for each 1-point increase in tophus score, the odds of frequent gout flares increased by 5.19 [(95%CI: 1.26-21.41), 7.91 [(95%CI: 2.23-28.14), and 13.79 [(95%CI: 3.79-50.20)] fold respectively. For the ankle, a tophus score of 3 markedly improved the prediction of the frequent flares [OR= 9.24 (95%CI=2.85-29.91)]. Semi-quantitative sum scores were associated with frequent flares with an OR (95%CI) of 13.66 (3.44-54.18), P < 0.001 at the MTP1, 7.05 (1.98-25.12), P < 0.001 at the ankle.

CONCLUSION

Ultrasound features of MSU crystal deposition at the MTP1 and knee predict subsequent risk of frequent gout flares in the same joints following initiation of urate-lowering therapy, with the highest risk in those with high tophus scores.

The Causal Relationship between Angina Pectoris and Gout Based on Two Sample Mendelian Randomization

Purpose

Two-sample Mendelian randomization (MR) was conducted to assess the causal relationship between angina pectoris and gout. Material and Methods. Based on genome-wide association studies, single nucleotide polymorphisms (SNPs) that were closely associated with gout were selected from the UK Biobank-Neale Lab (ukb-a-107) as genetic instrumental variables. Considering that gout is characterized by elevated blood uric acid levels, SNPs related to blood uric acid levels were screened from BioBank Japan (bbj-a-57) as auxiliary gene instrumental variables. SNPs closely associated with angina pectoris onset were screened from the FINN dataset (finn-b-I9_ANGINA) as outcome variables. Two-sample MR was conducted, with inverse variance weighting (IVW) of the random effects model as the primary result, along with the weighted median method (WME) and the MR-Egger regression method. To further confirm the causal relationship between angina and gout incidence, a meta-analysis was conducted on the IVW results of the ukb-a-107 and bbj-a-57.

Results

The odds ratios and 95% confidence intervals of the IVW, WME, and MR-Egger results of ukb-a-107 were (OR = 33.72; 95% CI: 2.07∼550.38), (OR = 57.94; 95% CI: 2.75∼1219.82), and (OR = 96.38; 95% CI: 0.6∼15556.93), respectively. The P values of IVW and WME were 0.014 and 0.014 (both <0.05), respectively, indicating that the development of angina pectoris was significantly associated with the incidence of gout. The odds ratios and 95% confidence intervals of the IVW, WME, and MR-Egger about bbj-a-57 were (OR = 1.20; 95% CI: 1.07∼1.34), (OR = 1.19; 95% CI: 1.02∼1.38), and (OR = 1.30; 95% CI; 1.06∼1.60), respectively. The P values of IVW, WME and MR-Egger were 0.001, 0.027 and 0.017 (all <0.05), respectively, indicating a significant correlation between angina and blood uric acid levels. Scatter plots of ukb-a-107 and bbj-a-57 showed that the causal association estimates of the IVW, MR-Egger, and weighted median methods were similar and that the MR results were accurate. Funnel plots and the MR-Egger intercept of ukb-a-107 and bbj-a-57 showed the absence of horizontal pleiotropy. The leave-out sensitivity analysis results of ukb-a-107 and bbj-a-57 are stable. The meta-analysis of IVW results for ukb-a-107 and bbj-a-57 showed (OR = 1.20; 95% CI: 1.07-1.34, P=0.02), confirming that gout characterized by high blood uric acid levels significantly increases the risk of angina attacks.

Conclusions

This MR study found a clear causal relationship between angina pectoris and gout, which increases the risk of angina pectoris.

Cognitive Status is Better in Older Adults under Colchicine Treatment: A Case-Control Study

PURPOSE

We aimed to investigate the effects of colchicine, an important anti-inflammatory agent, on cognitive functions in a geriatric population diagnosed with gout or osteoarthritis by comparing it to non-colchicine users.

METHODS

138 geriatric patients (67 colchicine users and 71 non-users) were enrolled. Within comprehensive geriatric assessment (CGA), cognitive status assessment via Mini-Mental State Examination test (MMSE), Quick Mild Cognitive Impairment Screening test (Qmci), clock drowning test (CDT), and digit span tests were performed.

RESULTS

Median age was 68 (65-72), and there were 82 female (59.4%) patients. The scores of CDT, Backward Digit Span Test, MMSE-Total, MMSE-Attention, MMSE-Motor Function, Qmci-Total Score, Qmci-Clock drawing, and Qmci-Logical Memory were significantly higher in the colchicine user group (p < .005), showing better cognitive function. Adjusted model analysis showed that colchicine usage is independently correlated with higher Qmci-Total Score and Qmci-Logical Memory Score (For Qmci total score β = 7.87 95%CI = 5.48-10.27, p = <0.0001, and for Qmci Logical memory score β = 3.52, 95%CI = 2.12-4.91, p = <0.0001).

CONCLUSION

To the best of our knowledge, this is the first study revealing that colchicine usage is associated with better cognitive performance in older adults. Further investigations with a prospective, larger-sampled and randomized design are needed to show the causal relationship between colchicine and cognition.

Unsupervised cluster analysis of clinical and ultrasound features reveals unique gout subtypes: Results from the Egyptian College of Rheumatology (ECR)

BACKGROUND

Gout comprises a heterogeneous group of disorders; however, comorbidities have been the focus of most efforts to classify disease subgroups.

OBJECTIVES

We applied cluster analysis using musculoskeletal ultrasound (MSUS) combined with clinical and laboratory findings in patients with gout to identify disease phenotypes, and differences across clusters were investigated.

PATIENTS AND METHODS

Patients with gout who complied with the ACR/EULAR classification criteria were enrolled in the Egyptian College of Rheumatology (ECR)-MSUS Study Group, a multicenter study. Selected variables included demographic, clinical, and laboratory findings. MSUS scans assessed the bilateral knee and first metatarsophalangeal joints. We performed a K-mean cluster analysis and compared the features of each cluster.

RESULTS

425 patients, 267 (62.8 %) males, mean age 54.2 ± 10.3 years were included. Three distinct clusters were identified. Cluster 1 (n = 138, 32.5 %) has the lowest burden of the disease and a lower frequency of MSUS characteristics than the other clusters. Cluster 2 (n = 140, 32.9 %) was mostly women, with a low rate of urate-lowering treatment (ULT). Cluster 3 (n = 147, 34.6 %) has the highest disease burden and the greatest proportion of comorbidities. Significant MSUS variations were found between clusters 2 and 3: joint effusion (p < 0.0001; highest: cluster 3), power Doppler signal (p < 0.0001; highest: clusters 2), and aggregates of crystal deposition (p < 0.0001; highest: cluster 3).

CONCLUSION

Cluster analysis using MSUS findings identified three gout subgroups. People with more MSUS features were more likely to receive ULT. Treatment should be tailored according to the cluster and MSUS features.

Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review

PURPOSE

Both heart failure and its treatment with diuretics or SGLT2 inhibitors increase fall risk in older adults. Therefore, decisions to continue or deprescribe diuretics or SGLT2 inhibitors in older heart failure patients who have fallen are generally highly complex and challenging for clinicians. However, a comprehensive overview of information required for rationale and safe decision-making is lacking. The aim of this clinical review was to assist clinicians in safe (de)prescribing of these drug classes in older heart failure patients.

METHODS

We comprehensively searched and summarized published literature and international guidelines on the efficacy, fall-related safety issues, and deprescribing of the commonly prescribed diuretics and SGLT2 inhibitors in older adults.

RESULTS

Both diuretics and SGLT2 inhibitors potentially cause various fall-related adverse effects. Their fall-related side effect profiles partly overlap (e.g., tendency to cause hypotension), but there are also important differences; based on the currently available evidence of this relatively new drug class, SGLT2 inhibitors seem to have a favorable fall-related adverse effect profile compared to diuretics (e.g., low/absent tendency to cause hyperglycemia or electrolyte abnormalities, low risk of worsening chronic kidney disease). In addition, SGLT2 inhibitors have potential beneficial effects (e.g., disease-modifying effects in heart failure, renoprotective effects), whereas diuretic effects are merely symptomatic.

CONCLUSION

(De)prescribing diuretics and SGLT2 inhibitors in older heart failure patients who have fallen is often highly challenging, but this clinical review paper assists clinicians in individualized and patient-centered rational clinical decision-making: we provide a summary of available literature on efficacy and (subclass-specific) safety profiles of diuretics and SGLT2 inhibitors, and practical guidance on safe (de)prescribing of these drugs (e.g. a clinical decision tree for deprescribing diuretics in older adults who have fallen).

Rutin ameliorates gout via reducing XOD activity, inhibiting ROS production and NLRP3 inflammasome activation in quail

Gout is a metabolic disease affected by monosodium urate (MSU) deposition, which is directly related to hyperuricemia. Recent reports on the prevalence and incidence of gout have been widely circulated worldwide. Currently, the anti-gout drugs in clinical practice are mainly small-molecule synthetic drugs, and the effectiveness and safety are limited. Reducing uric acid and inhibiting inflammation are the focused areas of drug research and development on gout. Rutin, a natural flavonoid, has been reported to alleviate inflammation in various diseases. However, whether rutin exerts protective effects on gout remains to be elucidated. This study used quails without urate oxidase as experimental animals to induce endogenous gout models through a high purine diet. We confirmed that quail in the model group developed gout symptoms at 30 days of the experiment. And the targets of uric acid metabolism, oxidative stress level, and NLRP3 inflammasome were dysregulated in quails. Rutin treatment improves gout and reduces inflammatory expression in quail. We further confirmed that rutin treatment reduced XOD activity and uric acid levels in quail. And rutin inhibited ROS production, restored oxidative stress balance, inhibited NLRP3 inflammasome activation, and exerted anti-inflammatory effects. We extracted and identified the fibroblast-like synoviocytes (FLS) for the first time. The results showed that rutin could reduce ROS production and NLRP3 inflammasome activation of FLS after uric acid stimulation. In conclusion, our findings underscore that rutin may be a gout protective agent by reducing XOD activity, inhibiting ROS production and NLRP3 inflammasome activation. Meanwhile, this study also provides an available animal model for the research drugs of gout.

Global status and trends in gout research from 2012 to 2021: a bibliometric and visual analysis

BACKGROUND

Gout is the most common inflammatory arthritis with an increasing prevalence and incidence across the globe. We aimed to provide a comprehensive and systematic knowledge map of gout research to determine its current status and trends over the past decade.

METHODS

Publications on gout research were obtained from the Web of Science Core Collection (WOSCC) database. Bibliometric R, VOSviewer, and Citespace were employed to analyze the eligible literature.

RESULTS

A total of 5535 publications concerning gout research between 2012 and 2021 were included. Most publications and citations both numerically came from China. The strongest international cooperation belonged to the USA. The University of Auckland was the most productive institution with a leading place in research collaboration. The prime funding agency was the National Natural Science Foundation of China. Most papers were published in Clinical Rheumatology. Annals of the Rheumatic Diseases achieved the highest number of citations, H-index and IF, which showed the most excellent comprehensive strength. The individual author with the most paper authorship was Dalbeth Nicola with 241 publications and 46 H-index. Keywords and co-citation analysis discovered that pathological mechanism remains the future hotspot in gout research. It may involve gout connection with gut microbiota, NLRP3 inflammasome, xanthine oxidase, and urate-transporter ABCG2. In addition, besides metabolic diseases, the relationship between gout and heart failure may need more attention.

CONCLUSION

This study clarified the current status and research frontier in gout over the past decade, which would provide valuable research references for later researchers. Key Points •We disclosed the current status and frontier directions of gout over the past 10 years worldwide. •We identified future hotspots of gout research, including gout connection with gut microbiota, NLRP3 inflammasome, xanthine oxidase, and urate-transporter ABCG2. •We discovered that the relationship between gout and heart status would be the research frontier.

Overnutrition-induced gout: An immune response to NLRP3 inflammasome dysregulation by XOD activity increased in quail

Background

Gout is a progressive metabolic disease closely related to hyperuricemia and urate deposition, with an increasing prevalence and incidence across the globe. Recent studies have shown that the pathological process of gout includes two stages: asymptomatic hyperuricemia and MSU crystal deposition. However, the immune response during the development of hyperuricemia to gouty arthritis is not fully elucidated.

Methods

Thus, an overnutrition-induced whole-course gout model was established to clarify the immune response and pathological changes in the development from hyperuricemia to gouty arthritis. The quails without urate oxidase were used as experimental animals. And we confirmed that uric acid metabolic targets were changed when quails were in the asymptomatic hyperuricemia stage.

Results

When the quail showed gout symptoms, the NLRP3 inflammasome was activated, and the expressions of IL-1β, TNF-α, IL-6, IL-8, and IL-18 were significantly increased. The relationship between the uric acid metabolism target and the NLRP3 inflammasome may be the critical immune response between hyperuricemia and gouty arthritis. Our data showed that, in the process of gout disease, the expression of xanthine oxidase (XOD) has been increasing, which increases the level of uric acid, disrupts the balance of oxidative stress, generates a large amount of ROS, activates the NLRP3 inflammasome, and release IL-1β. Treatment with the XOD inhibitor can reduce uric acid, restore the body's degree of peroxidative damage and antioxidant capacity, and inhibit NLRP3 inflammasome and IL-1β. In vitro, we extracted and identified primary fibroblast-like synoviocytes (FLS) from quail for the first time. Stimulating FLS with uric acid also caused ROS release and NLRP3 inflammasome activation. However, treatment with an XOD inhibitor prevented all these responses in FLS.

Conclusion

Our results indicate that the immune response between the uric acid metabolism target XOD and NLRP3 inflammasomes plays a crucial role in developing hyperuricemia to gouty arthritis, and inhibition of both XOD and NLRP3 inflammasomes may be an effective treatment for avoiding the development of asymptomatic hyperuricemia to MSU crystal deposition. Meanwhile, this study also provides an advantageous animal model for pathological mechanisms and research and development drugs for gout.

The combination of molecular docking and network pharmacology reveals the molecular mechanism of Danggui Niantong decoction in treating gout

BACKGROUND

Due to unhealthy diet and living habits, the incidence of gout is on the rise and has become a common disease with a high incidence. Danggui Niantong decoction (DGNTD), as a classic formula composed of 15 common herbs, has been widely used in clinical practice since ancient times to prevent and treat gout. However, the pharmacological mechanism and target of DGNTD are not clear.

METHODS

The potential active compounds and targets of DGNTD were obtained by traditional Chinese medicine systems pharmacology (TCMSP) database, and the differential genes of gout patients and controls were analyzed in gene expression omnibus (GEO) database. GSEA analysis of differential genes with GSEA 4.1.0 software and then the differential genes were intersected with the gout-related disease targets searched by GeneCard, CTD and OMIM disease database to obtain the final disease target. The "Traditional Chinese medicine-Active compounds-Targets" network was constructed by Cytoscape3.7.2 software. The R packet is used for enrichment analysis. The molecular docking between the active compound of DGNTD and the core target was verified by AutoDockTools software.

RESULTS

Two hundred eighty six and 244 targets of DGNTD-related active components and 652 targets of gout were obtained, of which 13 targets were potential targets of DGNTD in the treatment of gout. GSEA analysis showed that the differential genes were mainly involved in apoptosis, inflammatory reaction, and receptor metabolism and so on. Gene ontology (GO) functional enrichment analysis shows that DGNTD regulates many biological processes, such as the response to purine-containing compound and response to lipopolysaccharide, positive regulation of acute inflammatory response and other cellular components. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis shows that DGNTD treatment of gout is mainly related to interleukin-17 (IL-17), Toll-like receptor, rheumatoid arthritis, tumor necrosis factor (TNF) and so on. The results of molecular docking showed that the five active compounds in DGNTD had strong binding activity to core protein receptors.

CONCLUSIONS

The active compounds of DGNTD may achieve the purpose of treating gout by acting on the core target (CASP8, CXCL8, FOS, IL1B, IL6, JUN, PTGS2, STAT1, MMP1, TNF) to regulate cell metabolism, proliferation and apoptosis, and improve inflammatory response, which is the result of multi-component, multi-target and multi-pathway interaction. It provides an idea for the development of new combined drugs for gout.