Time to recognise gout as a chronic disease

To the Editor: In August 2019, the Australian Institute of Health and Welfare (AIHW) released a report on chronic musculoskeletal conditions in Australia.1

In the report, the prevalence of gout is estimated at 0.8% (equating to 187 000 people), based on self‐reported survey data. This rate is much smaller than previously reported in Australia. Recent South Australian population‐based studies using “self‐reported doctor diagnosed gout” as the case definition reported the prevalence of gout as being between 5.2% and 6.8%.2 Thus, the rate of self‐reported gout detailed in the AIHW report is incongruous with published data and appears to be unusually low.

The reported prevalence of gout in the AIHW document is based on the 2017–18 National Health Survey, in which participants were asked to self‐report doctor‐ or nurse‐diagnosed gout and whether the gout was current and expected to last for 6 months or more. Participants who did not identify as having current or long term gout did not have their condition recorded in the survey. Given that for most patients gout manifests as an intermittently flaring disease, with most flares lasting 7–10 days, respondents would likely not report their gout to be “current” or “likely to last 6 months” unless they have a clear understanding that gout is a chronic disease of monosodium urate crystal deposition. Many people with gout have not received this information from their health care providers and view the disease as present only when they are experiencing a flare.3 The chronic nature of the disease is reflected in the current definition of gout as “current or prior clinically evident disease”, as agreed by international gout experts.4 Gout is a systemic disease and an established independent risk factor for renal and cardiovascular disease. Like many chronic diseases, flares of gout and their long term consequences can be prevented with daily medication. However, both international and Australian evidence demonstrates that gout is inadequately treated, that persistence to urate‐lowering therapies is low, with suboptimal outcomes for patients.2 Under‐reporting and under‐recognition of gout and its burden on society is likely to contribute to undertreating and failure to manage it as a chronic disease — in contrast to other chronic conditions such as diabetes, in which the need for optimal disease management is well accepted.

It is important that the burden of gout in Australia is understood and accurately measured to allow optimal use of limited health resources, reduce burden on society, and improve outcomes for people with this condition. Quality data are required but must be generated with appropriate definitions.

We suggest that a validated case definition, such as “self‐reported gout” or “urate‐lowering therapies use”, be used in future Australian epidemiological studies.5