Gout prevalence is more common in Black Americans than white Americans, and the disparity in prevalence is attributable to social determinants of health, according to a recently published article in JAMA Network Open.
“There has been evidence from recent cohort studies in the US that was suggesting that the prevalence and incidence [of gout] was growing among nonwhite populations,” said Natalie McCormick, PhD, the study’s lead author and postdoctoral research fellow in medicine in the Division of Rheumatology, Allergy, and Immunology at Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. “We wanted to do this at the general population level to see how generalizable [that evidence] is.”
Alvin Wells, MD, PhD, director of the Department of Rheumatology at Advocate Aurora Medical Group, Franklin, Wisconsin, noted the findings highlight inequities in care for patients with gout that could be improved with greater emphasis on educating patients about their condition.
“I think that what this shows is that in the US…there still are some disparities in treating gout,” said Wells, who was not involved with the study. “And that we have ways to mitigate that, with not only aggressive therapy, but also with other tools like counseling patients. At the end of the day, people all want to be educated about the disease.”
Greater Prevalence Disappears With Adjustment for Socio-Clinical Factors
The cross-sectional analysis involved data from US adult participants in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016 who self-reported Black or white race.
Investigators considered factors such as excess body mass index (BMI), chronic kidney disease (CKD; defined as estimated glomerular filtration rate < 60 mL/min/1.73m2), poverty, poor-quality diet, lower educational level, alcohol consumption, and diuretic use in their analysis.
McCormick and co-investigators included a total of 18,693 participants, consisting of 3304 Black women, 6195 white women, 3085 Black men, and 6109 white men.
They determined that the age-standardized prevalence of gout was 3.5% (95% CI, 2.7% – 4.3%) in Black women and 2.0% (95% CI, 1.5% – 2.5%) in white women (age-adjusted odds ratio [OR], 1.81 [95% CI, 1.29 – 2.53]). They calculated that the prevalence was 7.0% (95% CI, 6.2% – 7.9%) in Black men and 5.4% (95% CI, 4.7%-6.2%) in white men (age-adjusted OR, 1.26 [95% CI, 1.02 – 1.55]). They found similar differences in the prevalence of hyperuricemia between Black and white Americans.
The increased prevalence of gout in Black Americans, compared with white Americans, does not arise from genetics, according to McCormick. “Our conclusion was that it was due to social determinants of health,” she said. “When we adjusted for all socio-clinical risk factors, the racial differences in gout and hyperuricemia prevalence disappeared. Importantly, stepwise regression analysis showed the two biggest drivers of the racial difference in gout prevalence among women were poverty itself, and excess BMI, which can be influenced by poverty.”
McCormick pointed out that in contrast to the current data, there was no racial difference in the prevalence of gout approximately two decades earlier, looking at data from the 1988-1994 NHANES III.
Given the findings, which included the fact that significantly more Black women and men were currently taking diuretics, compared with their white counterparts, McCormick pointed out clinicians should give more thought to medical therapies prescribed for conditions like high blood pressure to patients with gout or at risk for gout.
“One thing we found was that diuretic use was a driver” of gout, McCormick said. A prescriber “may want to consider different therapies that present a lower risk of gout if someone has hypertension. There could be greater consideration for prescribing alternatives to diuretics.”
More Patient Education and Rheumatology Referrals Needed
An impediment to providing that education to patients with gout is unconscious bias on the part of the primary care provider, Wells said.
“It is about what your perspectives are and what you bring to the table,” he explained. “If you saw [a patient] who looked like someone in your family, that person will be treated differently [than someone who does not look like a family member]. That is where the whole concept [of unconscious bias] comes in.”
Primary care providers need to adopt a holistic approach to gout management that involves counseling about good nutrition, smoking cessation, regular exercise, and limiting alcohol consumption, in addition to medication adherence. Primary care providers may have a bias in treating their Black patients, failing to devote sufficient time and attention to assist them in getting their disease under control, he said.
“Gout should be just like any other chronic disease,” Wells said. “You need to have a target in mind, and you and your patient need to work together to get to that target. When [patients] end up in rheumatology offices, it is almost too late. I think the take-home message here is that in 2022…for any patient who has gout, that patient probably needs to be seen by a rheumatologist because, indeed, with aggressive therapy, preventive therapy, [and] education, and if they are on the right medications, they won’t end up with these crippling joints that we see all the time.”
McCormick and Wells have disclosed no relevant financial relationships.
JAMA Netw Open. 2022;5(8):e2226804. Full Text