A/Prof Phil Robinson

Data and guidance on management of patients with rheumatic diseases and COVID-19 has accumulated rapidly through the course of the pandemic. Patients with gout, however, have largely not been included in those studies and treatment recommendations, representing an unmet need in the field, rheumatologists from Australia and NZ say.

“Given the high absolute risk of poor COVID-19 outcomes in people with gout, we believe that guidance is urgently needed to address the management of gout during the COVID-19 pandemic,” wrote Professor Philip Robinson of the University of Queensland and ProfessorNicola Dalbeth of the University of Auckland.

The relative paucity of research and information regarding gout is “probably a reflection that the most widespread concern in the field is about risks associated with immunosuppressing medications, which (with the exception of glucocorticoids) are not used for gout management,” they wrote in Lancet Rheumatology.. 

They note, though, that patients with gout should not be ignored in the context of COVID-19, given that the elevated risk of poor outcomes from the virus is found with many factors also associated with gout. It is more common in men than in women, and males are at higher risk for poor COVID-19 outcomes. Gout also occurs more often in older individuals, and is associated with overweight and obesity, cardiovascular disease, diabetes, and chronic kidney disease.

“These risk factors are even more pronounced in patients with gout who are referred to secondary or tertiary rheumatology clinics,” the authors wrote. A their secondary care rheumatology clinic, more than half of patients with gout had a 20% or higher risk of a cardiovascular event in five years, and a third of the patients had type 2 diabetes and 95% had overweight or obesity.

Gout is also more common among Indigenous people, Māori and Pacific Islanders. “Thus, the ethnic disparities in COVID-19 outcomes … are likely to further amplify the risk of poor outcomes in people with gout,” Profs Dalbeth and Robinson wrote.

There are specific management questions that have not yet been answered by research into rheumatic diseases and COVID-19. This includes whether prednisolone should be avoided for short-term management of gout flares when there is a high risk of SARS-CoV-2 exposure, and whether colchicine and anakinra are preferred options to manage the flares given their potential to improve outcomes of COVID-19.

There is also a need for guidance on continuing and ensuring the supply and delivery of urate-lowering therapy. “In times of disrupted health-care delivery, ensuring that patients receive regular urate-lowering therapy and have a safe action plan for gout flares is essential for effective management,” the authors wrote. 

The positive results of the COLCORONA trial may increase demand for colchicine, potentially making access to the agent difficult for patients with gout. In the UK, the PRINCIPLE trial recently expanded to include a colchicine arm as a potential treatment for early COVID-19.

“The COVID-19 pandemic has been a major concern for rheumatologists,” Profs Dalbeth and Robinson wrote. “We wish to highlight that, even when patients with gout are not taking immunosuppressants, their comorbidities mean that they have among the highest risk of poor COVID-19-related outcomes of all patients with rheumatic diseases.”