Sunday, March 22, 2009

Gouty Arthritis : History and Development in Asian Regions

There are few studies of crystal arthropathy, although there have been many reports of cases of gout in Asia. Like other parts of the world, gout in Asian countries is frequently found in middle aged men and may lead to deformities and disabilities.

EPIDEMIOLOGY

The prevalence of gout varies from one population to another and within populations between geographical areas. Any assessment of the incidence of gout in any population group will depend upon the criteria used to establish the diagnosis. Previous reports revealed that the incidence of hyperuricemia and gout is higher in a number of Asian races living in the USA than in comparable groups living in their homeland.1 For instance the rate of hyperuricemia and gout among the Filipinos living in Hongkong or in United States is significantly higher than those living in their native countries.1, 2
There is evidence that the distribution of serum uric acid (SUA) has changed, more people are now showing higher SUA levels with subsequent increased risk for gout.3 The three ethnic groups in Malaysia, the Malay (Malayo-Polynesians), Tamils and Chinese (Mongoloid) showed higher mean SUA levels compared with most Caucasian populations. This suggests that the influence of environmental factors might be of significance.4
The WHO-ILAR-COPCORD stage I phase 3 research in Bandungan, central Java, Indonesia, showed that the frequency of hyperuricemia and gout in males 15 years of age and over is high compared with Caucasian population. This is despite a lower life expectancy, low social class, and abstinence of alcohol and subsistence economy. The prevalence of gout was 0.8% in the 4.683 people 15 years and older. The overall male to female ratio was thirty-four to one. Gout occurred in 1.7% of the men and 0.05% of the women. It was predominantly found in men over 45 years. Acute gouty arthritis and chronic tophaceous gout were both found in this population sample.5
In Taiwan, it was found that the incidence of gout in rural and urban area were 13.6/1,000 and 6.4/1,000 respectively while the prevalence of gout were 0.6% (rural) and 0.67% (urban).6 In the clinical study of 45 gout patients in Ujung Pandang (South Sulawesi, Indonesia) the rate of hyperuricemia was 88.0%7 while in North Sulawesi, it was found that among the 208 chronic gout patients, 92.3% had hyperuricemia8. The occurrence of gout was frequent in the patients' family in North Sulawesi.

CLINICAL FEATURES AND COMPLICATIONS

In several Asian countries, the clinical features of gout seem to be different from Western countries. In the northern part of Thailand it was found that of 75 patients analyzed, the mean age was 58 years. The mean duration of disease was 6.7 years. Ankles were the most common sites of attack (45%) followed by first metatarsophalangeal joint (28%) and knee (24%). Tophi were present in 47% with the mean disease duration before onset of tophi was 5.6 years. Fifty five percent had impaired renal function (creatinine > 1.5 mg/dl). Urinary stones were found in 33%, hypertension in 56% and diabetes mellitus in 7% of patients.9 The study of gouty arthritis and uric acid levels in several ethnic groups in Ujung Pandang, South Sulawesi, Indonesia suggest that in Indonesia gout is a common and severe arthritic condition for which patients often present too late for effective treatment. More than 50% of patients with tophi have noted these for 7 – 9 years before coming for their first treatment. Tophaceous gout was not clearly associated with any one ethnic group.7
A study of 190 chronic tophaceous gout patients in North Sulawesi, Indonesia, showed that about 32.2% of patients experienced their first attack of gout when they were less than 34 years old. Multiple tophi and deformities were found in 80% of cases, they had tophi for 5 – 10 years, and kidney stones were found in 12% of cases.
In University Santo Thomas Hospital, Philippines, a study found 6 males developing gout before age 20, 44 patients between 20 - 29 years of age, and another subgroup of 124 males. With disease onset between 30 – 39 years. The youngest male patient was 12 years old. These patients was characterized by an earlier onset of gouty arthritis, with an average age of 20 years, leading to more severe joint involvement and tophaceous deposition, more severe renal damage with kidney stone formation. Uncommon clinical presentation of gout were found in this country, such as those involving pre-menopausal women, early onset in males polyarticular gout, the occurrence of gout with systemic lupus erythematosus and rheumatoid arthritis and some unusual sites of urate deposition.10
In Malaysian study, the clinical features of gout were similar to other Asian countries. Renal stones and positive family history were noticed in 42% and 30% respectively.11 A retrospective study in Alexandria hospital, Singapore, disclosed that 66% of cases (n: 51) were obese with body mass index >25. The commonest joint involvement was MTP I (51%), knees (49%), and ankles (46%). Tophi were noticed in 31% of cases.12

TREATMENT

The COPCORD survey in Indonesia indicated that more than 60% of rheumatic patients had sought help from the rural or urban primary health centers (PHCs), general practitioner, or nurses or primary health care workers. It was also found that 74% of the urban and 71% of the rural population with rheumatism resorted to self medication by buying “over the counter” tablets and capsules. These drugs were found to be prescription drugs containing glucocorticoid or phenylbutazone or a mixture of both. With their spectacular short-term therapeutic relief of joint inflammation and pain these agents are apt to increase in popularity 5. Thiazid diuretics (HCT) are widely used in community health centers in Indonesia.
A study in South Sulawesi revealed that patients first come for treatment after an average of 6.6 years following the first attack of gout.7 A survey in North Sulawesi found that there were no urate lowering drugs available in PHCs in this area. Most patients had never received any adequate treatment for gout.8



CONCLUSION

Based on several studies in some Asia countries, it was found that clinical features of gout seem to be different from Western countries. Gout patients seen in the Philippines and Northern Sulawesi (Indonesia) and northern part of Thailand were younger than other countries.
The duration of gout in Thailand and South Sulawesi (Indonesia) are similar. Overweight was found in the study Singapore and North Sulawesi (Indonesia), however in Thailand, most of gout patients were underweight and malnourished. First attack of gout in most Asian countries such as Indonesia, Singapore was at the first metatarsophalangeal, however in Thailand, the ankle was the most frequently affected joint. Tophi were found in most countries such as Indonesia, Singapore, and Thailand. Hypertension and kidney involvement was reported as the frequent complication in these areas.
Thiazide diuretics were used in the PHCs to treat high blood pressure and were suspected as a risk factor for gout. There was no report from other Asian countries regarding the treatment of gout in their countries.
Further studies are needed to clarify the differences of pattern of gout from one country to another.

REFERENCES

1. Emmerson B.T. Incidence of Gout in Different Populations. Hyperuricemia and Gout in Clinical Practice, 1983:70.
2. Zimmet P.Z, Whitehouse S, Jackson L, Thoma K. High Prevalence of Hyperuricemia and Gout in an Urbanized Micronesian Population. Br Med J 1878;1:1237-9.
3. Roubenoff R. Incidence and Prevalence of Gouty arthritis. Rheum Dis Clin of North America 1990:16(3):
4. Darmawan J, Valkenburg H, Muirden KD, Wigley RD. The Epidemiology of Gout and Hyperuricemia in a Rural Population of Java. J Rheumatol 1992;19:1595-9.
5. Darmawan J, Rheumatic Conditions in Nortern Part of Central Java. An Epidemiological Survey. MD Erasmus University Rotterdam, 1988;147-50 (thesis).
6. Chou CT, Pei L, Chang DM, Lee CF, Schumacher HR Jr, Liang MH. Prevalence of Rheumatic Disease in Taiwan: A Population Study of Urban, Suburban, Rural Diggerences. J Rheumatol 1994;21:302-6.
7. Tehupeiory E. Gouty Arthritis and Uric Acid Distribution in Several Ethnic Groups in Ujung Pandang, 1992 (thesis).
8. Padang C, Muirden KD, Schumacher HR. Chronic Tophaceous Gout in the Northern Part of Sulawesi. Proceeding of the Eight APLAR Congress of Rheumatology. Melbourne 1996.
9. Louthrenoo W. Gout Arthritis in the Northern Part of Thailand. Proceeding of the Third ASEAN Congress of Rheumatology, Bangkok, Thailand, 1991.
10. Torralba T, Buenviaga MB, Navarra SV. Some uncommon Clinical Presentation of Gout. Proceeding of the Third ASEAN Congress of Rheumatology, Bangkok, Thailand, 1991.
11. Shahdan MS. Clinical Spectrum of Gout in Malaysia. Proceeding of the Third ASEAN Congress of Rheumatology, Bangkok, Thailand, 1991.
12. Lai YL, Ng SC. Clinical Profile of Gouty arthritis. Fourth ASEA Congres of Rheumatology, Singapore, 1994.

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