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Māori and Pacific People over-represented in GOUT clinics
Gout is the most common form of inflammatory arthritis affecting men.29 Gout is uncommon in pre-menopausal women. Most women with gout are post-menopausal and taking diuretics.
Gout is on the increase in New Zealand.30 Recent data from primary care in Auckland shows that gout affects 14.9% Pacific men, 9.3% Māori men and 4.1% European men (Richard Hulme, East Tamaki Health Care, 2006). The same data has shown that gout is more frequently diagnosed than Type II diabetes in Māori and Pacific Island men.
Gout is now the most frequent cause for new patient referral to the rheumatology outpatient clinic in South Auckland, and accounts for more than 200 inpatient admissions to Middlemore Hospital each year.31 Māori and Pacific patients with severe gout are over-represented within gout clinics in the Auckland area (Table 1).
Table 1. Percentage of Māori and Pacific Island people presenting to gout clinics in Counties Manukau DHB.13
% DHB population
% presenting to
gout clinics
Māori
17%
25.6%
Pacific Island
16%
46.0%
Māori and Pacific patients attending these rheumatology clinics have higher serum uric acid levels, more work disability and lower levels of musculoskeletal function than European patients (N. Dalbeth, unpublished data).
Why is gout such a problem in Māori and Pacific communities?
Genetic research into the causes of gout
Renal excretion of urate is controlled by a number of organic anion transporters and URAT1, the specific urate transporter that reabsorbs urate from the proximal renal tubules into the bloodstream. Genetic variants in URAT1 have been demonstrated to be a primary cause of gout in overseas populations. Researchers at the University of Otago, in collaboration with the New Zealand Rheumatology Research Network and Ngati Porou Hauora, are testing the URAT1 gene and other urate transport molecules for genetic variants causative of gout in patients of Māori and Pacific ancestry. Patients with variants in URAT1, that are a primary cause of gout, may benefit from treatment with uricosuric agents such as benzbromarone and probenecid which specifically inhibit the activity of URAT1. (J.Hollis-Moffatt,personal communication)
A study of gout patients in South Auckland has revealed some key issues (personal communication, Dr K Lindsay, CMDHB).
There is minimal knowledge about gout and the medications used in treatment.
Amongst the Pacific Island community in particular, there is a normalisation of gout, a stoicism and tolerance of the pain.
Often knowledge of gout is based on jokes about over-indulgence, old age or unhelpful myths.
These beliefs contribute to denial and result in missed opportunities for early diagnosis.
Families take up the burden of caring for gout patients and these patients rarely present to general practice.
Typically patients will use pain relief but not preventative medications, with a resulting increase in the number of joints involved, the size of tophi, the frequency of attacks and number of days off work. Without appropriate use of allopurinol, their gout is progressive and becomes chronic.
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