Gout Risk High in Those With Psoriasis, Psoriatic Arthritis

Janis C. Kelly

March 28, 2014

Individuals with psoriasis have nearly twice the risk, and those with psoriatic arthritis (PsA) have nearly 5 times as high a risk, for gout as those without psoriasis, according to the first prospective cohort study to address this relationship.

The age- and multivariate-adjusted relative risks (HRs) for gout were 1.71 (95% confidence interval [CI], 1.36 - 2.15) for psoriasis and 4.95 (95% CI, 2.72 - 9.01) for psoriasis with concomitant PsA, report Joseph F. Merola, MD, from the Department of Dermatology and the Division of Rheumatology, Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, and colleagues. They present their findings in an article published online in the Annals of the Rheumatic Diseases.

In Arthrocentesis for PsA, Also Look for Gout

"There are some diagnostic implications when seeing a patient with psoriasis and/or [PsA] who presents with joint inflammation," Dr. Merola told Medscape Medical News. "The clinician should include the possibility of crystal disease flare in light of the increased association in the differential diagnosis in addition to [PsA] flare. If arthrocentesis is performed for a joint inflammation event, evaluation for monosodium urate (gout) crystals should be performed."

Psoriasis–Gout Link Based on Cohort Study of 98,810 Persons

The study was based on 2 cohorts of men and women from the Health Professionals Follow-Up Study (1986 - 2010) and the Nurses' Health Study (1998 - 2010), respectively. The analysis included 27,751 men and 71,059 women, with 2217 incident cases of gout during the follow-up periods of 24 years for men and 12 years for women. Participants were queried in 2008 about physician-diagnosed psoriasis. The investigators confirmed psoriasis diagnoses using the Psoriasis Screening Tool questionnaire and PsA diagnoses using the PsA screening and evaluation questionnaire.

Incident gout cases were assessed using the American College of Rheumatology gout survey criteria. Participants were then questioned every 2 years about whether and when they had received a physician diagnosis of incident gout.

The primary end point was incident cases of gout that met 6 or more of these criteria: more than 1 attack of acute arthritis, maximum inflammation developed within 1 day, oligoarthritis attack, redness observed over joints, painful or swollen first metatarsophalangeal joint, unilateral first metatarsophalangeal joint attack, unilateral tarsal joint attack, tophus, hyperuricemia, asymmetric swelling within a joint, and complete termination of an attack.

Covariate analysis included weight, smoking, use of diuretics, use of aspirin, type 2 diabetes, hypertension menopausal status, and postmenopausal hormone use, physical activity, and diet.

In Asymmetric, Inflammatory PsA Synovitis, Consider Gout

Among those with confirmed psoriasis, multivariate-adjusted HRs for gout were 2.72 (95% CI, 1.75 - 4.25) in men and 1.40 (95% CI, 0.90 - 2.19) in women. In those with psoriasis and PsA, the HR for incident gout rose to 4.95 (95% CI, 2.72 - 9.01); this risk was similar for men and for women.

The risks were somewhat higher for those participants with a baseline diagnosis of psoriasis (multivariate HR for gout, 1.84; 95% CI, 1.09 - 3.09) and for those with a baseline diagnosis of psoriasis and concomitant PsA at baseline (pooled multivariate HR, 5.23; 95% CI, 2.70 - 10.1).

In contrast, there was little association between risk for incident gout and history of rheumatoid arthritis. History of osteoarthritis was associated with a significant but small increase in gout risk (HR, 1.15; 95% CI, 0.99 - 1.35).

Gout risk was higher among men than among women, rose with age in women, and decreased with age in men.

"Overall the risk estimates were substantial and demonstrate a clear association between a prior history of psoriasis, with or without concomitant PsA, and incident gout," the authors write.

"Clinically, an awareness of the relationship between psoriasis, PsA and gout is therefore particularly important when evaluating the psoriasis patient for possible inflammatory arthritis symptoms," they add. "In those individuals presenting with an asymmetric, inflammatory synovitis, our findings clearly highlight the need to consider inflammatory crystal arthopathy in the differential diagnosis of psoriasis patients presenting with an acutely inflamed joint(s)."

"These are convincing data, since they used 2 prospective large databases and were able to register and adjust the risk considering many factors, including dietary ones and comorbidities. I think that they did consider all the relevant factors," psoriasis expert Paolo Gisondi, MD, from the Department of Medicine, Section of Dermatology and Venereology, University of Verona, Italy, told Medscape Medical News. Dr. Gisondi, who was not involved in the study, recently published a study on hyperuricemia in patients with chronic plaque psoriasis.

Watch for Elevated Uric Acid, Gout Flare in Psoriasis?

Dr. Gisondi advised, "I think that serum uric acid should be monitored by dermatologists and rheumatologists routinely in patients with moderate to severe psoriasis and PsA, and urate-lowering therapy be considered in cases of increased levels of uric acid, particularly if concomitant metabolic disorders are present."

Dr. Merola took a more cautious approach, noting that the study "would imply, but does not prove" that monitoring elevated uric acid blood levels and clinically evaluating for gout flare among psoriasis or PsA patients might be beneficial in preventing or early diagnosis of gout.

Or Treat Psoriasis to Prevent Gout?

"Other work would suggest that weight loss and dietary modification would likely decrease the severity and frequency of psoriasis, [PsA,] and gout flares. We may speculate that controlling psoriatic skin and joint disease could decrease uric acid levels, and therefore [the] risk of incident gout," Dr. Merola said.

Senior author Abrar A. Qureshi, MD, MPH, from the Department of Dermatology and the Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, also is cautious in his interpretation of the data. "Our findings suggest a causal link between psoriasis and development of gout. This makes sense as psoriasis is a systemic inflammatory disorder with rapid cell turnover. However, from this study we cannot infer that psoriasis treatment would reduce gout flares."

Dr. Merola serves as a consultant for Biogen Idec, is on an advisory board for Amgen, is an investigator for Amgen, and has received research grants from Biogen Idec. One coauthor serves as a consultant for Abbott, Centocor, and Novartis; another coauthor has served on advisory boards for Takeda Pharmaceuticals and Astra-Zeneca Pharmaceuticals and has received research grants from Takeda Pharmaceuticals and Savient Pharmaceuticals. The other authors and Dr. Gisondi have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online March 20, 2014. Abstract

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