An interesting article published by Dalbeth and Robinson in The Lancet rheumatology March 9th 2021 discusses this issue.
There has been a rapid acceleration in the understanding of predictors for poor outcomes of SARS-CoV-2 infection since first reports of COVID-19 in late 2019.
Amongst rheumatologists this is primarily focused on the risks of those outcomes in patients with autoimmune inflammatory rheumatic disease, particularly those undergoing immunosuppressive therapy.
Overall, the risk profile is favourable for patients with rheumatic diseases or taking many commonly used medicines including non-steroidal anti-inflammatories, hydroxychloroquine, methotrexate and most biologics.
However, moderate dose and high dose steroids, Rituximab, sulfasalazine and transplantation like immunosuppressants are associated with poorer outcomes.
It is noted that although detailed advice has been provided for patients with autoimmune rheumatic diseases and for those taking disease modifying antirheumatic drugs and immunosuppressant medication, the management of patients with gout has not been specifically mentioned.
This probably reflects the fact that immunosuppressive medications are not routinely used within gout management.
However, the omission of gout from recent recommendations is surprising given that the absolute risk for poor outcomes after SARS-CoV-2 infection in people with gout is likely to be amongst the highest among all patients with rheumatic diseases.
In the general population, gout is associated with many risk factors for poorer COVID-19 outcomes such as:
- It is more common in men than in women.
- It occurs more often in older individuals.
- It is strongly associated with overweight and obesity.
- Cardiovascular disease.
- Diabetes.
- Chronic kidney disease.
These risk factors are even more pronounced in patients with gout who are referred for secondary or tertiary care in the rheumatology clinics.
The authors states that previous analysis from their secondary care rheumatology clinic showed that more than half of patients with gout had a very high calculated risk equal to higher than 20% of a cardiovascular event within five years – this was mostly due to existing cardiovascular disease or diabetic nephropathy.
A third of the patients had type two diabetes and 95% were overweight or obese.
The ethnic disparities in COVID-19 outcomes appear to amplify the risk of poor outcomes in people with gout.
As we know, COVID-19 outcomes have a higher rate of hospitalisation and death in people of non-white ethnicity, including African Americans in the USA and indigenous people compared with white or ethnic minority groups.
The authors suggest that given the high absolute risk of poor COVID-19 outcomes in people with gout that they believe guidance is urgently needed to address the management of gout during the COVID-19 pandemic.
They also suggest that there should be further research in this high risk group.
They suggest that consideration should be given as to whether short term management of gout flares when there is a high risk of SARS-CoV-2 exposure should be offered prednisolone.
They consider whether colchicine and anakinra should be preferred options for the management of gout flares given their potential to improve outcomes in the context of severe COVID-19.
They also consider whether there is an additional benefit in adding daily low dose colchicine as gout flare prophylaxis when there is a high risk of SARS-CoV-2 exposure.
They suggest that patients have reported more difficulty with gout flares during the pandemic and in this time of disrupted healthcare delivery, they feel it is important that patients receive regular urate lowering therapy and have a safe action plan for gout flares with effective management.
They conclude that there are few classes of medications that are associated with an increased risk of poor outcomes but importantly, they suggest that comorbidity risks should be carefully examined because they can substantially increase the risk of poor outcomes and are more common in patients with rheumatic diseases.
They suggest and highlight that patients with gout have the highest risk of poor COVID-19 related outcomes of all patients with rheumatic diseases as a result of their comorbidities.
The London General Practice continually reassesses its treatment approaches and management protocols and suggest that any patient suffering with gout should seek consultation so that an appropriate management plan can be arranged.
Dr Paul Ettlinger
BM, DRCOG, FRCGP, FRIPH, DOccMed